Treatment of fabry disease in ert-naïve and ert-experienced patients

ABSTRACT

Provided are dosing regimens for the treatment of Fabry disease in a patient. Certain methods relate to the treatment of ERT-experienced or ERT-nave Fabry patients. Certain methods comprise administering to the patient about 123 mg free base equivalent of migalastat for improving left ventricular mass and/or improving podocyte globotriaosylceramide.

TECHNICAL FIELD

Principles and embodiments of the present invention relate generally to the use of pharmacological chaperones for the treatment of lysosomal storage disorders, particularly the use of migalastat for the treatment of Fabry disease.

BACKGROUND

Fabry disease is a progressive, X-linked inborn error of glycosphingolipid metabolism caused by a deficiency in the lysosomal enzyme α-galactosidase A (α-Gal A) as a result of mutations in the α-Gal A gene (GLA). Despite being an X-linked disorder, females can express varying degrees of clinical manifestations. Fabry is a rare disease with incidence estimated between 1 in 40,000 males to 1 in 117,000 in the general population. Moreover, there are variants of later onset phenotype of Fabry disease that can be under-diagnosed, as they do not present with classical signs and symptoms. This, and newborn screening for Fabry disease, suggests that the actual incidence of Fabry disease can be higher than currently estimated.

Untreated, life expectancy in Fabry patients is reduced and death usually occurs in the fourth or fifth decade because of vascular disease affecting the kidneys, heart and/or central nervous system. The enzyme deficiency leads to intracellular accumulation of the substrate, globotriaosylceramide (GL-3) in the vascular endothelium and visceral tissues throughout the body. Gradual deterioration of renal function and the development of azotemia, due to glycosphingolipid deposition, usually occur in the third to fifth decades of life, but can occur as early as in the second decade. Renal lesions are found in both hemizygous (male) and heterozygous (female) patients.

Cardiac disease as a result of Fabry disease occurs in most males and many females. Early cardiac findings include left ventricular enlargement, valvular involvement and conduction abnormalities. Mitral insufficiency is the most frequent valvular lesion typically present in childhood or adolescence. Cerebrovascular manifestations result primarily from multifocal small-vessel involvement and can include thromboses, transient ischemic attacks, basilar artery ischemia and aneurysm, seizures, hemiplegia, hemianesthesia, aphasia, labyrinthine disorders, or cerebral hemorrhages. Average age of onset of cerebrovascular manifestations is 33.8 years. Personality change and psychotic behavior can manifest with increasing age.

The current FDA-approved treatment for Fabry disease is enzyme replacement therapy (ERT). Two α-Gal A products are currently available for the treatment of Fabry disease: agalsidase alfa (Replagal®, Shire Human Genetic Therapies) and agalsidase beta (Fabrazyme®; Genzyme Corporation). These two forms of ERT are intended to compensate for a patient's inadequate α-Gal A activity with a recombinant form of the enzyme, administered intravenously. While ERT is effective in many settings, the treatment also has limitations. ERT has not been demonstrated to decrease the risk of stroke, cardiac muscle responds slowly, and GL-3 elimination from some of the cell types of the kidneys is limited. Some patients also develop immune reactions to ERT.

Accordingly, there remains a need for therapies for the treatment of Fabry disease.

SUMMARY

Various aspects of the present invention relate to the treatment of Fabry disease in ERT-naïve and ERT-experienced patients using migalastat.

One aspect of the present invention pertains to a method of reducing left ventricular mass index (LVMi) in an ERT-experienced patient having Fabry disease, the method comprising administering to the patient a formulation comprising an effective amount of migalastat or salt thereof every other day, wherein the effective amount is about 123 mg free base equivalent (FBE).

In one or more embodiments, the patient has left ventricular hypertrophy (LVH) prior to initiating administration of the migalastat or salt thereof.

In one or more embodiments, the migalastat or salt thereof enhances α-Gal A activity.

In one or more embodiments, the patient is administered about 123 mg of migalastat free base every other day.

In one or more embodiments, the patient is administered about 150 mg of migalastat hydrochloride every other day.

In one or more embodiments, the formulation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, a capsule or a solution.

In one or more embodiments, the migalastat or salt thereof is administered for at least 18 months.

In one or more embodiments, the migalastat or salt thereof is administered for at least 30 months.

In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-experienced patients of at least about 5 g/m² after 18 months of administration of migalastat or a salt thereof. In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-experienced patients of about 6.6 g/m² after 18 months of administration of migalastat or a salt thereof.

In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-experienced patients of at least about 2 g/m² after 30 months of administration of migalastat or a salt thereof. In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-experienced patients of about 3.8 g/m² after 30 months of administration of migalastat or a salt thereof.

In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-experienced patients with LVH of at least about 5 g/m² after 30 months of administration of migalastat or a salt thereof. In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-experienced patients with LVH of about 9 g/m² after 30 months of administration of migalastat or a salt thereof.

Another aspect of the present invention pertains to a method of reducing LVMi in an ERT-naïve patient having Fabry disease, the method comprising administering to the patient a formulation comprising an effective amount of migalastat or salt thereof every other day, wherein the effective amount is about 123 mg FBE.

In one or more embodiments, the patient has LVH prior to initiating administration of the migalastat or salt thereof.

In one or more embodiments, the migalastat or salt thereof enhances α-Gal A activity.

In one or more embodiments, the patient is administered about 123 mg of migalastat free base every other day.

In one or more embodiments, the patient is administered about 150 mg of migalastat hydrochloride every other day.

In one or more embodiments, the formulation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, a capsule or a solution.

In one or more embodiments, the migalastat or salt thereof is administered for at least 18 months.

In one or more embodiments, the migalastat or salt thereof is administered for at least 30 months.

In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-naïve patients of at least about 5 g/m² after 18 to 24 months of administration of migalastat or a salt thereof. In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-naïve patients of about 7.7 g/m² after 18 to 24 months of administration of migalastat or a salt thereof.

In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-naïve patients of at least about 10 g/m² after 30 to 36 months of administration of migalastat or a salt thereof. In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-naïve patients of about 17 g/m² after 30 to 36 months of administration of migalastat or a salt thereof.

In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-experienced patients with LVH of at least about 15 g/m² after 30 to 36 months of administration of migalastat or a salt thereof. In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-naïve patients with LVH of about 20.8 g/m² after 30 to 36 months of administration of migalastat or a salt thereof.

Another aspect of the present invention pertains to a method of normalizing LVMi in a patient having Fabry disease, the method comprising administering to the patient a formulation comprising an effective amount of migalastat or salt thereof every other day, wherein the effective amount is about 123 mg FBE.

In one or more embodiments, the patient has LVH prior to initiating administration of the migalastat or salt thereof.

In one or more embodiments, the migalastat or salt thereof enhances α-Gal A activity.

In one or more embodiments, the patient is administered about 123 mg of migalastat free base every other day.

In one or more embodiments, the patient is administered about 150 mg of migalastat hydrochloride every other day.

In one or more embodiments, the formulation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, a capsule or a solution.

In one or more embodiments, the migalastat or salt thereof is administered for at least 18 months.

In one or more embodiments, the migalastat or salt thereof is administered for at least 30 months.

Another aspect of the present invention pertains to a method of normalizing LVMi in an ERT-experienced patient having Fabry disease, the method comprising administering to the patient a formulation comprising an effective amount of migalastat or salt thereof every other day, wherein the effective amount is about 123 mg FBE.

In one or more embodiments, the patient has LVH prior to initiating administration of the migalastat or salt thereof.

In one or more embodiments, the migalastat or salt thereof enhances α-Gal A activity.

In one or more embodiments, the patient is administered about 123 mg of migalastat free base every other day.

In one or more embodiments, the patient is administered about 150 mg of migalastat hydrochloride every other day.

In one or more embodiments, the formulation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, a capsule or a solution.

In one or more embodiments, the migalastat or salt thereof is administered for at least 18 months.

In one or more embodiments, the migalastat or salt thereof is administered for at least 30 months.

In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-experienced patients of at least about 5 g/m² after 18 months of administration of migalastat or a salt thereof. In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-experienced patients of about 6.6 g/m² after 18 months of administration of migalastat or a salt thereof.

In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-experienced patients of at least about 2 g/m² after 30 months of administration of migalastat or a salt thereof. In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-experienced patients of about 3.8 g/m² after 30 months of administration of migalastat or a salt thereof.

In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-experienced patients with LVH of at least about 5 g/m² after 30 months of administration of migalastat or a salt thereof. In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-experienced patients with LVH of about 9 g/m² after 30 months of administration of migalastat or a salt thereof.

Another aspect of the present invention pertains to a method of normalizing LVMi in an ERT-naïve patient having Fabry disease, the method comprising administering to the patient a formulation comprising an effective amount of migalastat or salt thereof every other day, wherein the effective amount is about 123 mg FBE.

In one or more embodiments, the patient has LVH prior to initiating administration of the migalastat or salt thereof.

In one or more embodiments, the migalastat or salt thereof enhances α-Gal A activity.

In one or more embodiments, the patient is administered about 123 mg of migalastat free base every other day.

In one or more embodiments, the patient is administered about 150 mg of migalastat hydrochloride every other day.

In one or more embodiments, the formulation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, a capsule or a solution.

In one or more embodiments, the migalastat or salt thereof is administered for at least 18 months.

In one or more embodiments, wherein the migalastat or salt thereof is administered for at least 30 months.

In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-naïve patients of at least about 5 g/m² after 18 to 24 months of administration of migalastat or a salt thereof. In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-naïve patients of about 7.7 g/m² after 18 to 24 months of administration of migalastat or a salt thereof.

In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-naïve patients of at least about 10 g/m² after 30 to 36 months of administration of migalastat or a salt thereof. In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-naïve patients of about 17 g/m² after 30 to 36 months of administration of migalastat or a salt thereof.

In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-naïve patients with LVH of at least about 15 g/m² after 30 to 36 months of administration of migalastat or a salt thereof. In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-naïve patients with LVH of about 20.8 g/m² after 30 to 36 months of administration of migalastat or a salt thereof.

Another aspect of the present invention pertains to a method of reducing podocyte GL-3 in a patient having Fabry disease, the method comprising administering to the patient a formulation comprising an effective amount of migalastat or salt thereof every other day, wherein the effective amount is about 123 mg FBE.

In one or more embodiments, the migalastat or salt thereof enhances α α-Gal A activity.

In one or more embodiments, the patient is administered about 123 mg of migalastat free base every other day.

In one or more embodiments, the patient is administered about 150 mg of migalastat hydrochloride every other day.

In one or more embodiments, the formulation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, a capsule or a solution.

In one or more embodiments, the migalastat or salt thereof is administered for at least 6 months.

In one or more embodiments, the patient is an ERT-naïve patient.

In one or more embodiments, the patient is an ERT-experienced patient.

Another aspect of the present invention pertains to a method of reducing podocyte volume in a patient having Fabry disease, the method comprising administering to the patient a formulation comprising an effective amount of migalastat or salt thereof every other day, wherein the effective amount is about 123 mg FBE.

In one or more embodiments, the migalastat or salt thereof enhances α-Gal A activity.

In one or more embodiments, the patient is administered about 123 mg of migalastat free base every other day.

In one or more embodiments, the patient is administered about 150 mg of migalastat hydrochloride every other day.

In one or more embodiments, the formulation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, a capsule or a solution.

In one or more embodiments, the migalastat or salt thereof is administered for at least 6 months.

In one or more embodiments, the administration of migalastat or a salt thereof provides an average reduction of podocyte volume in a group of ERT-naive patients of at least about 30% after 6 months of administration of migalastat or a salt thereof.

In one or more embodiments, the administration of migalastat or a salt thereof provides an average reduction of podocyte volume in a group of ERT-naive patients of about 47% after 6 months of administration of migalastat or a salt thereof.

In one or more embodiments, the patient is an ERT-naïve patient.

In one or more embodiments, the patient is an ERT-experienced patient.

Another aspect of the present invention pertains to a method of reducing GL-3 inclusion volume per podocyte in a patient having Fabry disease, the method comprising administering to the patient a formulation comprising an effective amount of migalastat or salt thereof every other day, wherein the effective amount is about 123 mg FBE.

In one or more embodiments, the migalastat or salt thereof enhances α-Gal A activity.

In one or more embodiments, the patient is administered about 123 mg of migalastat free base every other day.

In one or more embodiments, the patient is administered about 150 mg of migalastat hydrochloride every other day.

In one or more embodiments, the formulation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, a capsule or a solution.

In one or more embodiments, the migalastat or salt thereof is administered for at least 6 months.

In one or more embodiments, the administration of migalastat or a salt thereof provides an average reduction of GL-3 inclusion volume per podocyte in a group of ERT-naive patients of at least about 30% after 6 months of administration of migalastat or a salt thereof.

In one or more embodiments, the administration of migalastat or a salt thereof provides an average reduction of GL-3 inclusion volume per podocyte in a group of ERT-naive patients of about 50% after 6 months of administration of migalastat or a salt thereof.

In one or more embodiments, the patient is an ERT-naïve patient.

In one or more embodiments, the patient is an ERT-experienced patient.

Another aspect of the present invention pertains to a method of treating Fabry disease in an ERT-experienced patient, the method comprising administering to the patient a formulation comprising an effective amount of migalastat or salt thereof every other day, wherein the effective amount is about 123 mg FBE and wherein administering the formulation reduces the patient's left ventricular mass (LVM).

In one or more embodiments, the patient has left ventricular hypertrophy (LVH) prior to initiating administration of the migalastat or salt thereof.

In one or more embodiments, the migalastat or salt thereof enhances α-Gal A activity.

In one or more embodiments, the patient is administered about 123 mg of migalastat free base every other day.

In one or more embodiments, the patient is administered about 150 mg of migalastat hydrochloride every other day.

In one or more embodiments, the formulation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, a capsule or a solution.

In one or more embodiments, the migalastat or salt thereof is administered for at least 18 months.

In one or more embodiments, the migalastat or salt thereof is administered for at least 30 months.

In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-experienced patients of at least about 5 g/m² after 18 months of administration of migalastat or a salt thereof. In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-experienced patients of about 6.6 g/m² after 18 months of administration of migalastat or a salt thereof.

In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-experienced patients of at least about 2 g/m² after 30 months of administration of migalastat or a salt thereof. In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-experienced patients of about 3.8 g/m² after 30 months of administration of migalastat or a salt thereof.

In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-experienced patients with LVH of at least about 5 g/m² after 30 months of administration of migalastat or a salt thereof. In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-experienced patients with LVH of about 9 g/m² after 30 months of administration of migalastat or a salt thereof.

Another aspect of the present invention pertains to a method of treating Fabry disease in an ERT-naïve patient, the method comprising administering to the patient a formulation comprising an effective amount of migalastat or salt thereof every other day, wherein the effective amount is about 123 mg FBE and wherein administering the formulation reduces the patient's LVM.

In one or more embodiments, the patient has LVH prior to initiating administration of the migalastat or salt thereof.

In one or more embodiments, the migalastat or salt thereof enhances α-Gal A activity.

In one or more embodiments, the patient is administered about 123 mg of migalastat free base every other day.

In one or more embodiments, the patient is administered about 150 mg of migalastat hydrochloride every other day.

In one or more embodiments, the formulation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, a capsule or a solution.

In one or more embodiments, the migalastat or salt thereof is administered for at least 18 months.

In one or more embodiments, the migalastat or salt thereof is administered for at least 30 months.

In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-naïve patients of at least about 5 g/m² after 18 to 24 months of administration of migalastat or a salt thereof. In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-naïve patients of about 7.7 g/m² after 18 to 24 months of administration of migalastat or a salt thereof.

In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-naïve patients of at least about 10 g/m² after 30 to 36 months of administration of migalastat or a salt thereof. In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-naïve patients of about 17 g/m² after 30 to 36 months of administration of migalastat or a salt thereof.

In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-experienced patients with LVH of at least about 15 g/m² after 30 to 36 months of administration of migalastat or a salt thereof. In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-naïve patients with LVH of about 20.8 g/m² after 30 to 36 months of administration of migalastat or a salt thereof.

Another aspect of the present invention pertains to a method of treating Fabry disease, the method comprising administering to a patient in need a formulation comprising an effective amount of migalastat or salt thereof every other day, wherein the effective amount is about 123 mg FBE and wherein administering the formulation normalizes the patient's LVMi.

In one or more embodiments, the patient has LVH prior to initiating administration of the migalastat or salt thereof.

In one or more embodiments, the migalastat or salt thereof enhances α-Gal A activity.

In one or more embodiments, the patient is administered about 123 mg of migalastat free base every other day.

In one or more embodiments, the patient is administered about 150 mg of migalastat hydrochloride every other day.

In one or more embodiments, the formulation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, a capsule or a solution.

In one or more embodiments, the migalastat or salt thereof is administered for at least 18 months.

In one or more embodiments, the migalastat or salt thereof is administered for at least 30 months.

Another aspect of the present invention pertains to a method of treating Fabry disease in an ERT-experienced patient, the method comprising administering to the patient a formulation comprising an effective amount of migalastat or salt thereof every other day, wherein the effective amount is about 123 mg FBE and wherein administering the formulation normalizes the patient's LVMi.

In one or more embodiments, the patient has LVH prior to initiating administration of the migalastat or salt thereof.

In one or more embodiments, the migalastat or salt thereof enhances α-Gal A activity.

In one or more embodiments, the patient is administered about 123 mg of migalastat free base every other day.

In one or more embodiments, the patient is administered about 150 mg of migalastat hydrochloride every other day.

In one or more embodiments, the formulation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, a capsule or a solution.

In one or more embodiments, the migalastat or salt thereof is administered for at least 18 months.

In one or more embodiments, the migalastat or salt thereof is administered for at least 30 months.

In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-experienced patients of at least about 5 g/m² after 18 months of administration of migalastat or a salt thereof. In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-experienced patients of about 6.6 g/m² after 18 months of administration of migalastat or a salt thereof.

In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-experienced patients of at least about 2 g/m² after 30 months of administration of migalastat or a salt thereof. In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-experienced patients of about 3.8 g/m² after 30 months of administration of migalastat or a salt thereof.

In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-experienced patients with LVH of at least about 5 g/m² after 30 months of administration of migalastat or a salt thereof. In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-experienced patients with LVH of about 9 g/m² after 30 months of administration of migalastat or a salt thereof.

Another aspect of the present invention pertains to a method of treating Fabry disease in an ERT-naïve patient, the method comprising administering to the patient a formulation comprising an effective amount of migalastat or salt thereof every other day, wherein the effective amount is about 123 mg FBE and wherein administering the formulation normalizes the patient's LVMi.

In one or more embodiments, the patient has LVH prior to initiating administration of the migalastat or salt thereof.

In one or more embodiments, the migalastat or salt thereof enhances α-Gal A activity.

In one or more embodiments, the patient is administered about 123 mg of migalastat free base every other day.

In one or more embodiments, the patient is administered about 150 mg of migalastat hydrochloride every other day.

In one or more embodiments, the formulation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, a capsule or a solution.

In one or more embodiments, the migalastat or salt thereof is administered for at least 18 months.

In one or more embodiments, wherein the migalastat or salt thereof is administered for at least 30 months.

In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-naïve patients of at least about 5 g/m² after 18 to 24 months of administration of migalastat or a salt thereof. In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-naïve patients of about 7.7 g/m² after 18 to 24 months of administration of migalastat or a salt thereof.

In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-naïve patients of at least about 10 g/m² after 30 to 36 months of administration of migalastat or a salt thereof. In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-naïve patients of about 17 g/m² after 30 to 36 months of administration of migalastat or a salt thereof.

In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-naïve patients with LVH of at least about 15 g/m² after 30 to 36 months of administration of migalastat or a salt thereof. In one or more embodiments, the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-naïve patients with LVH of about 20.8 g/m² after 30 to 36 months of administration of migalastat or a salt thereof.

Another aspect of the present invention pertains to a method of treating Fabry disease, the method comprising administering to a patient in need a formulation comprising an effective amount of migalastat or salt thereof every other day, wherein the effective amount is about 123 mg FBE and wherein administering the formulation reduces podocyte GL-3 in the patient.

In one or more embodiments, the migalastat or salt thereof enhances α α-Gal A activity.

In one or more embodiments, the patient is administered about 123 mg of migalastat free base every other day.

In one or more embodiments, the patient is administered about 150 mg of migalastat hydrochloride every other day.

In one or more embodiments, the formulation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, a capsule or a solution.

In one or more embodiments, the migalastat or salt thereof is administered for at least 6 months.

In one or more embodiments, the patient is an ERT-naïve patient.

In one or more embodiments, the patient is an ERT-experienced patient.

Another aspect of the present invention pertains to a method of treating Fabry disease, the method comprising administering to a patient in need a formulation comprising an effective amount of migalastat or salt thereof every other day, wherein the effective amount is about 123 mg FBE and wherein administering the formulation reduces podocyte volume in the patient.

In one or more embodiments, the migalastat or salt thereof enhances α-Gal A activity.

In one or more embodiments, the patient is administered about 123 mg of migalastat free base every other day.

In one or more embodiments, the patient is administered about 150 mg of migalastat hydrochloride every other day.

In one or more embodiments, the formulation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, a capsule or a solution.

In one or more embodiments, the migalastat or salt thereof is administered for at least 6 months.

In one or more embodiments, the administration of migalastat or a salt thereof provides an average reduction of podocyte volume in a group of ERT-naive patients of at least about 30% after 6 months of administration of migalastat or a salt thereof.

In one or more embodiments, the administration of migalastat or a salt thereof provides an average reduction of podocyte volume in a group of ERT-naive patients of about 47% after 6 months of administration of migalastat or a salt thereof.

In one or more embodiments, the patient is an ERT-naïve patient.

In one or more embodiments, the patient is an ERT-experienced patient.

Another aspect of the present invention pertains to a method of treating Fabry disease, the method comprising administering to a patient in need a formulation comprising an effective amount of migalastat or salt thereof every other day, wherein the effective amount is about 123 mg FBE and wherein administering the formulation reduces GL-3 inclusion volume per podocyte in the patient.

In one or more embodiments, the migalastat or salt thereof enhances α-Gal A activity.

In one or more embodiments, the patient is administered about 123 mg of migalastat free base every other day.

In one or more embodiments, the patient is administered about 150 mg of migalastat hydrochloride every other day.

In one or more embodiments, the formulation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, a capsule or a solution.

In one or more embodiments, the migalastat or salt thereof is administered for at least 6 months.

In one or more embodiments, the administration of migalastat or a salt thereof provides an average reduction of GL-3 inclusion volume per podocyte in a group of ERT-naive patients of at least about 30% after 6 months of administration of migalastat or a salt thereof.

In one or more embodiments, the administration of migalastat or a salt thereof provides an average reduction of GL-3 inclusion volume per podocyte in a group of ERT-naive patients of about 50% after 6 months of administration of migalastat or a salt thereof.

In one or more embodiments, the patient is an ERT-naïve patient.

In one or more embodiments, the patient is an ERT-experienced patient.

BRIEF DESCRIPTION OF THE DRAWINGS

Further features of the present invention will become apparent from the following written description and the accompanying figures, in which:

FIGS. 1A-E show the full DNA sequence of the human wild-type GLA gene (SEQ ID NO: 1).

FIG. 2 shows the wild-type α-Gal A protein (SEQ ID NO: 2).

FIG. 3 shows the average LVMi changes from baseline to after 6/12, 18/24 and 30/36 months of migalastat therapy, as described in Example 1.

FIG. 4 shows (A) individual changes in GL-3 inclusion volume per podocyte from baseline to after 6 months of migalastat treatment; (B) glomerulus from a patient with Fabry disease at baseline and (C) after 6 months of treatment, as described in Example 1.

FIG. 5 shows (A) individual changes in podocyte volume from baseline to after 6 months of migalastat treatment; (B) correlation between podocyte volume and podocyte inclusion volume after 6 months of treatment; (C) volume fraction of GL-3 inclusions in podocytes (podocyte inclusion volume/podocyte volume) at baseline and after 6 months of treatment, as described in Example 1.

FIG. 6 shows (A) average foot process width in patients with Fabry disease at baseline or after 6 months of migalastat treatment compared with 9 healthy controls; (B) correlation between change in foot process width and change in GL-3 inclusions volume per podocyte, as described in Example 1.

FIG. 7 shows (A) individual changes in plasma lyso-Gb3 from baseline to after 6 months of migalastat treatment; individual comparisons between changes in plasma lyso-Gb3 with (B) changes in volume fraction of GL-3 inclusions in podocytes and (C) changes in GL-3 inclusion volume, as described in Example 1.

FIG. 8 shows independent comparisons of change in 24-hour urine protein with (A) change in volume fraction of GL-3 inclusions in podocytes and (B) GL-3 inclusion volume, as described in Example 1.

FIG. 9 shows the urine GL-3 levels in female patients on migalastat therapy, as described in Example 3.

FIG. 10 shows the urine GL-3 levels in male patients on migalastat therapy, as described in Example 3.

DETAILED DESCRIPTION

Before describing several exemplary embodiments of the invention, it is to be understood that the invention is not limited to the details of construction or process steps set forth in the following description. The invention is capable of other embodiments and of being practiced or being carried out in various ways.

Various aspects of the present invention pertain to dosing regimens for the administration of pharmacological chaperones such as migalastat for the treatment of Fabry disease. In one or more embodiments, the dosing regimens of migalastat improve one or more cardiac parameters and/or one or more renal parameters of a patient.

Definitions

The terms used in this specification generally have their ordinary meanings in the art, within the context of this invention and in the specific context where each term is used. Certain terms are discussed below, or elsewhere in the specification, to provide additional guidance to the practitioner in describing the compositions and methods of the invention and how to make and use them.

The term “Fabry disease” refers to an X-linked inborn error of glycosphingolipid catabolism due to deficient lysosomal α-Gal A activity. This defect causes accumulation of the substrate globotriaosylceramide (“GL-3”, also known as Gb3 or ceramide trihexoside) and related glycosphingolipids in vascular endothelial lysosomes of the heart, kidneys, skin, and other tissues.

The term “atypical Fabry disease” refers to patients with primarily cardiac manifestations of the α-Gal A deficiency, namely progressive GL-3 accumulation in myocardial cells that leads to significant enlargement of the heart, particularly the left ventricle.

A “carrier” is a female who has one X chromosome with a defective α-Gal A gene and one X chromosome with the normal gene and in whom X chromosome inactivation of the normal allele is present in one or more cell types. A carrier is often diagnosed with Fabry disease.

A “patient” refers to a subject who has been diagnosed with or is suspected of having a particular disease. The patient may be human or animal.

A “Fabry patient” refers to an individual who has been diagnosed with or suspected of having Fabry disease and has a mutated α-Gal A as defined further below. Characteristic markers of Fabry disease can occur in male hemizygotes and female carriers with the same prevalence, although females typically are less severely affected.

The term “ERT-naïve patient” refers to a Fabry patient that has never received ERT or has not received ERT for at least 6 months prior to initiating migalastat therapy.

The term “ERT-experienced patient” refers to a Fabry patient that was receiving ERT immediately prior to initiating migalastat therapy. In some embodiments, the ERT-experienced patient has received at least 12 months of ERT immediately prior to initiating migalastat therapy.

Human α-galactosidase A (α-Gal A) refers to an enzyme encoded by the human GLA gene. The full DNA sequence of α-Gal A, including introns and exons, is available in GenBank Accession No. X14448.1 and shown in SEQ ID NO: 1 and FIGS. 1A-E. The human α-Gal A enzyme consists of 429 amino acids and is available in GenBank Accession Nos. X14448.1 and U78027.1 and shown in SEQ ID NO: 2 and FIG. 2.

The term “mutant protein” includes a protein which has a mutation in the gene encoding the protein which results in the inability of the protein to achieve a stable conformation under the conditions normally present in the endoplasmic reticulum. The failure to achieve a stable conformation results in a substantial amount of the enzyme being degraded, rather than being transported to the lysosome. Such a mutation is sometimes called a “conformational mutant.” Such mutations include, but are not limited to, missense mutations, and in-frame small deletions and insertions.

As used herein in one embodiment, the term “mutant α-Gal A” includes an α-Gal A which has a mutation in the gene encoding α-Gal A which results in the inability of the enzyme to achieve a stable conformation under the conditions normally present in the endoplasmic reticulum. The failure to achieve a stable conformation results in a substantial amount of the enzyme being degraded, rather than being transported to the lysosome.

As used herein, the term “pharmacological chaperone” (“PC”) refers to any molecule including a small molecule, protein, peptide, nucleic acid, carbohydrate, etc. that specifically binds to a protein and has one or more of the following effects: (i) enhances the formation of a stable molecular conformation of the protein; (ii) induces trafficking of the protein from the endoplasmic reticulum to another cellular location, preferably a native cellular location, i.e., prevents endoplasmic reticulum-associated degradation of the protein; (iii) prevents aggregation of misfolded proteins; and/or (iv) restores or enhances at least partial wild-type function and/or activity to the protein. A compound that specifically binds to e.g., α-Gal A, means that it binds to and exerts a chaperone effect on the enzyme and not a generic group of related or unrelated enzymes. More specifically, this term does not refer to endogenous chaperones, such as BiP, or to non-specific agents which have demonstrated non-specific chaperone activity against various proteins, such as glycerol, DMSO or deuterated water, i.e., chemical chaperones. In one or more embodiments of the present invention, the PC may be a reversible competitive inhibitor.

A “competitive inhibitor” of an enzyme can refer to a compound which structurally resembles the chemical structure and molecular geometry of the enzyme substrate to bind the enzyme in approximately the same location as the substrate. Thus, the inhibitor competes for the same active site as the substrate molecule, thus increasing the Km. Competitive inhibition is usually reversible if sufficient substrate molecules are available to displace the inhibitor, i.e., competitive inhibitors can bind reversibly. Therefore, the amount of enzyme inhibition depends upon the inhibitor concentration, substrate concentration, and the relative affinities of the inhibitor and substrate for the active site.

As used herein, the term “specifically binds” refers to the interaction of a pharmacological chaperone with a protein such as α-Gal A, specifically, an interaction with amino acid residues of the protein that directly participate in contacting the pharmacological chaperone. A pharmacological chaperone specifically binds a target protein, e.g., α-Gal A, to exert a chaperone effect on the protein and not a generic group of related or unrelated proteins. The amino acid residues of a protein that interact with any given pharmacological chaperone may or may not be within the protein's “active site.” Specific binding can be evaluated through routine binding assays or through structural studies, e.g., co-crystallization, NMR, and the like. The active site for α-Gal A is the substrate binding site.

“Deficient α-Gal A activity” refers to α-Gal A activity in cells from a patient which is below the normal range as compared (using the same methods) to the activity in normal individuals not having or suspected of having Fabry or any other disease (especially a blood disease).

As used herein, the terms “enhance α-Gal A activity” or “increase α-Gal A activity” refer to increasing the amount of α-Gal A that adopts a stable conformation in a cell contacted with a pharmacological chaperone specific for the α-Gal A, relative to the amount in a cell (preferably of the same cell-type or the same cell, e.g., at an earlier time) not contacted with the pharmacological chaperone specific for the α-Gal A. This term also refers to increasing the trafficking of α-Gal A to the lysosome in a cell contacted with a pharmacological chaperone specific for the α-Gal A, relative to the trafficking of α-Gal A not contacted with the pharmacological chaperone specific for the protein. These terms refer to both wild-type and mutant α-Gal A. In one embodiment, the increase in the amount of α-Gal A in the cell is measured by measuring the hydrolysis of an artificial substrate in lysates from cells that have been treated with the PC. An increase in hydrolysis is indicative of increased α-Gal A activity.

The term “α-Gal A activity” refers to the normal physiological function of a wild-type α-Gal A in a cell. For example, α-Gal A activity includes hydrolysis of GL-3.

A “responder” is an individual diagnosed with or suspected of having a lysosomal storage disorder, such, for example Fabry disease, whose cells exhibit sufficiently increased α-Gal A activity, respectively, and/or amelioration of symptoms or improvement in surrogate markers, in response to contact with a PC. Non-limiting examples of improvements in surrogate markers for Fabry are lyso-GB3 and those disclosed in U.S. Patent Application Publication No. US 2010/0113517.

Non-limiting examples of improvements in surrogate markers for Fabry disease disclosed in U.S. 2010/0113517 include increases in α-Gal A levels or activity in cells (e.g., fibroblasts) and tissue; reductions in of GL-3 accumulation; decreased plasma concentrations of homocysteine and vascular cell adhesion molecule-1 (VCAM-1); decreased GL-3 accumulation within myocardial cells and valvular fibrocytes; reduction in plasma globotriaosylsphingosine (lyso-Gb3); reduction in cardiac hypertrophy (especially of the left ventricle), amelioration of valvular insufficiency, and arrhythmias; amelioration of proteinuria; decreased urinary concentrations of lipids such as CTH, lactosylceramide, ceramide, and increased urinary concentrations of glucosylceramide and sphingomyelin; the absence of laminated inclusion bodies (Zebra bodies) in glomerular epithelial cells; improvements in renal function; mitigation of hypohidrosis; the absence of angiokeratomas; and improvements hearing abnormalities such as high frequency sensorineural hearing loss progressive hearing loss, sudden deafness, or tinnitus. Improvements in neurological symptoms include prevention of transient ischemic attack (TIA) or stroke; and amelioration of neuropathic pain manifesting itself as acroparaesthesia (burning or tingling in extremities). Another type of clinical marker that can be assessed for Fabry disease is the prevalence of deleterious cardiovascular manifestations.

As used herein, the term “normalizing LVMi” refers to reducing the LVMi of a patient from an above-normal range to within the normal range. The normal range of LVMi for a female is 43-95 g/m² and the normal range of LVMi for a male is 49-115 g/m². Thus, normalizing LVMi for a female patient is reducing LVMi from >95 g/m² to within the range of 43-95 g/m², and normalizing LVMi for a male patient is reducing LVMi from >115 g/m² to within the range of 49-115 g/m².

The phrase “pharmaceutically acceptable” refers to molecular entities and compositions that are physiologically tolerable and do not typically produce untoward reactions when administered to a human. In some embodiments, as used herein, the term “pharmaceutically acceptable” means approved by a regulatory agency of the Federal or a state government or listed in the U.S. Pharmacopoeia or other generally recognized pharmacopoeia for use in animals, and more particularly in humans. The term “carrier” in reference to a pharmaceutical carrier refers to a diluent, adjuvant, excipient, or vehicle with which the compound is administered. Such pharmaceutical carriers can be sterile liquids, such as water and oils. Water or aqueous solution saline solutions and aqueous dextrose and glycerol solutions are preferably employed as carriers, particularly for injectable solutions. Suitable pharmaceutical carriers are described in “Remington's Pharmaceutical Sciences” by E. W. Martin, 18th Edition, or other editions.

The term “enzyme replacement therapy” or “ERT” refers to the introduction of a non-native, purified enzyme into an individual having a deficiency in such enzyme. The administered protein can be obtained from natural sources or by recombinant expression (as described in greater detail below). The term also refers to the introduction of a purified enzyme in an individual otherwise requiring or benefiting from administration of a purified enzyme, e.g., suffering from enzyme insufficiency. The introduced enzyme may be a purified, recombinant enzyme produced in vitro, or protein purified from isolated tissue or fluid, such as, e.g., placenta or animal milk, or from plants.

As used herein, the term “isolated” means that the referenced material is removed from the environment in which it is normally found. Thus, an isolated biological material can be free of cellular components, i.e., components of the cells in which the material is found or produced. In the case of nucleic acid molecules, an isolated nucleic acid includes a PCR product, an mRNA band on a gel, a cDNA, or a restriction fragment. In another embodiment, an isolated nucleic acid is preferably excised from the chromosome in which it may be found, and more preferably is no longer joined to non-regulatory, non-coding regions, or to other genes, located upstream or downstream of the gene contained by the isolated nucleic acid molecule when found in the chromosome. In yet another embodiment, the isolated nucleic acid lacks one or more introns. Isolated nucleic acids include sequences inserted into plasmids, cosmids, artificial chromosomes, and the like. Thus, in a specific embodiment, a recombinant nucleic acid is an isolated nucleic acid. An isolated protein may be associated with other proteins or nucleic acids, or both, with which it associates in the cell, or with cellular membranes if it is a membrane-associated protein. An isolated organelle, cell, or tissue is removed from the anatomical site in which it is found in an organism. An isolated material may be, but need not be, purified.

The terms “about” and “approximately” shall generally mean an acceptable degree of error for the quantity measured given the nature or precision of the measurements. Typical, exemplary degrees of error are within 20 percent (%), preferably within 10%, and more preferably within 5% of a given value or range of values. Alternatively, and particularly in biological systems, the terms “about” and “approximately” may mean values that are within an order of magnitude, preferably within 10- or 5-fold, and more preferably within 2-fold of a given value. Numerical quantities given herein are approximate unless stated otherwise, meaning that the term “about” or “approximately” can be inferred when not expressly stated.

Fabry Disease

Fabry disease is a rare, progressive and devastating X-linked lysosomal storage disorder. Mutations in the GLA gene result in a deficiency of the lysosomal enzyme, α-Gal A, which is required for glycosphingolipid metabolism. Beginning early in life, the reduction in α-Gal A activity results in an accumulation of glycosphingolipids, including GL-3 and plasma lyso-Gb3, and leads to the symptoms and life-limiting sequelae of Fabry disease, including pain, gastrointestinal symptoms, renal failure, cardiomyopathy, cerebrovascular events, and early mortality. Early initiation of therapy and lifelong treatment provide an opportunity to slow disease progression and prolong life expectancy.

Fabry disease encompasses a spectrum of disease severity and age of onset, although it has traditionally been divided into 2 main phenotypes, “classic” and “late-onset”. The classic phenotype has been ascribed primarily to males with undetectable to low α-Gal A activity and earlier onset of renal, cardiac and/or cerebrovascular manifestations. The late-onset phenotype has been ascribed primarily to males with higher residual α-Gal A activity and later onset of these disease manifestations. Heterozygous female carriers typically express the late-onset phenotype but depending on the pattern of X-chromosome inactivation may also display the classic phenotype.

More than 800 Fabry disease-causing GLA mutations have been identified. Approximately 60% are missense mutations, resulting in single amino acid substitutions in the α-Gal A enzyme. Missense GLA mutations often result in the production of abnormally folded and unstable forms of α-Gal A and the majority are associated with the classic phenotype. Normal cellular quality control mechanisms in the endoplasmic reticulum block the transit of these abnormal proteins to lysosomes and target them for premature degradation and elimination. Many missense mutant forms are targets for migalastat, an α-Gal A-specific pharmacological chaperone.

The clinical manifestations of Fabry disease span a broad spectrum of severity and roughly correlate with a patient's residual α-Gal A levels. The majority of currently treated patients are referred to as classic Fabry patients, most of whom are males. These patients experience disease of various organs, including the kidneys, heart and brain, with disease symptoms first appearing in adolescence and typically progressing in severity until death in the fourth or fifth decade of life. A number of recent studies suggest that there are a large number of undiagnosed males and females that have a range of Fabry disease symptoms, such as impaired cardiac or renal function and strokes, that usually first appear in adulthood. Individuals with this type of Fabry disease, referred to as later-onset Fabry disease, tend to have higher residual α-Gal A levels than classic Fabry patients. Individuals with later-onset Fabry disease typically first experience disease symptoms in adulthood, and often have disease symptoms focused on a single organ, such as enlargement of the left ventricle or progressive kidney failure. In addition, later-onset Fabry disease may also present in the form of strokes of unknown cause.

Fabry patients have progressive kidney impairment, and untreated patients exhibit end-stage renal impairment by the fifth decade of life. Deficiency in α-Gal A activity leads to accumulation of GL-3 and related glycosphingolipids in many cell types including cells in the kidney. GL-3 accumulates in podocytes, epithelial cells and the tubular cells of the distal tubule and loop of Henle. Impairment in kidney function can manifest as proteinuria and reduced glomerular filtration rate.

Because Fabry disease is rare, involves multiple organs, has a wide age range of onset, and is heterogeneous, proper diagnosis is a challenge. Awareness is low among health care professionals and misdiagnoses are frequent. Diagnosis of Fabry disease is most often confirmed on the basis of decreased α-Gal A activity in plasma or peripheral leukocytes (WBCs) once a patient is symptomatic, coupled with mutational analysis. In females, diagnosis is even more challenging since the enzymatic identification of carrier females is less reliable due to random X-chromosomal inactivation in some cells of carriers. For example, some obligate carriers (daughters of classically affected males) have α-Gal A enzyme activities ranging from normal to very low activities. Since carriers can have normal α-Gal A enzyme activity in leukocytes, only the identification of an α-Gal A mutation by genetic testing provides precise carrier identification and/or diagnosis.

Mutant forms of α-Gal A are considered to be amenable to migalastat are defined as showing a relative increase (+10 μM migalastat) of ≥1.20-fold and an absolute increase (+10 μM migalastat) of ≥3.0% wild-type (WT) when the mutant form of α-Gal A is expressed in HEK-293 cells (referred to as the “HEK assay”) according to Good Laboratory Practice (GLP)-validated in vitro assay (GLP HEK or Migalastat Amenability Assay). Such mutations are also referred to herein as “HEK assay amenable” mutations.

Previous screening methods have been provided that assess enzyme enhancement prior to the initiation of treatment. For example, an assay using HEK-293 cells has been utilized in clinical trials to predict whether a given mutation will be responsive to pharmacological chaperone (e.g., migalastat) treatment. In this assay, cDNA constructs are created. The corresponding α-Gal A mutant forms are transiently expressed in HEK-293 cells. Cells are then incubated ±migalastat (17 nM to 1 mM) for 4 to 5 days. After, α-Gal A levels are measured in cell lysates using a synthetic fluorogenic substrate (4-MU-α-Gal) or by western blot. This has been done for known disease-causing missense or small in-frame insertion/deletion mutations. Mutations that have previously been identified as responsive to a PC (e.g., migalastat) using these methods are listed in U.S. Pat. No. 8,592,362.

Pharmacological Chaperones

The binding of small molecule inhibitors of enzymes associated with LSDs can increase the stability of both mutant enzyme and the corresponding wild-type enzyme (see U.S. Pat. Nos. 6,274,597; 6,583,158; 6,589,964; 6,599,919; 6,916,829, and 7,141,582 all incorporated herein by reference). In particular, administration of small molecule derivatives of glucose and galactose, which are specific, selective competitive inhibitors for several target lysosomal enzymes, effectively increased the stability of the enzymes in cells in vitro and, thus, increased trafficking of the enzymes to the lysosome. Thus, by increasing the amount of enzyme in the lysosome, hydrolysis of the enzyme substrates is expected to increase. The original theory behind this strategy was as follows: since the mutant enzyme protein is unstable in the endoplasmic reticulum (Ishii et al., Biochem. Biophys. Res. Comm. 1996; 220: 812-815), the enzyme protein is retarded in the normal transport pathway (endoplasmic reticulum→Golgi apparatus→endosomes→lysosome) and prematurely degraded. Therefore, a compound which binds to and increases the stability of a mutant enzyme, may serve as a “chaperone” for the enzyme and increase the amount that can exit the endoplasmic reticulum and move to the lysosomes. In addition, because the folding and trafficking of some wild-type proteins is incomplete, with up to 70% of some wild-type proteins being degraded in some instances prior to reaching their final cellular location, the chaperones can be used to stabilize wild-type enzymes and increase the amount of enzyme which can exit the endoplasmic reticulum and be trafficked to lysosomes.

In one or more embodiments, the pharmacological chaperone comprises migalastat or salt thereof. As used herein, “migalastat” refers to (2R,3S,4R,5S)-2-(hydroxymethyl) piperdine-3,4,5-triol, and is also known as 1-deoxygalactonojirimycin and known under trade name Galafold™. In further embodiments, the pharmacological chaperone comprises the hydrochloride salt of migalastat. Migalastat has the following structure:

As used herein, the term “free base equivalent” or “FBE” refers to the amount of migalastat present in the migalastat or salt thereof. In other words, the term “FBE” means either an amount of migalastat free base, or the equivalent amount of migalastat free base that is provided by a salt of migalastat. For example, due to the weight of the hydrochloride salt, 150 mg of migalastat hydrochloride only provides as much migalastat as 123 mg of the free base form of migalastat. Other salts will have different conversion factors, depending on the molecular weight of the salt.

Migalastat is a low molecular weight iminosugar and is an analogue of the terminal galactose of GL-3. In vitro and in vivo pharmacologic studies have demonstrated that migalastat acts as a pharmacological chaperone, selectively and reversibly binding, with high affinity, to the active site of wild-type (WT) α-Gal A and specific mutant forms of α-Gal A, the genotypes of which are referred to as HEK assay amenable mutations. Migalastat binding stabilizes these mutant forms of α-Gal A in the endoplasmic reticulum facilitating their proper trafficking to lysosomes where dissociation of migalastat allows α-Gal A to reduce the level of GL-3 and other substrates. Approximately 30-50% of patients with Fabry disease have HEK assay amenable mutations; the majority of which are associated with the classic phenotype of the disease. A list of HEK assay amenable mutations includes at least those mutations listed in Table 1 below. In one or more embodiments, if a double mutation is present on the same chromosome (males and females), that patient is considered HEK assay amenable if the double mutation is present in one entry in Table 1 (e.g., D55V/Q57L). In some embodiments, if a double mutation is present on different chromosomes (only in females) that patient is considered HEK assay amenable if either one of the individual mutations is present in Table 1.

TABLE 1 Amenable Mutations Nucleotide change Nucleotide change Protein sequence change c.7C > G c.C7G L3V c.8T > C c.T8C L3P c.[11G > T; 620A > C] c.G11T/A620C R4M/Y207S c.37G > A c.G37A A13T c.37G > C c.G37C A13P c.43G > A c.G43A A15T c.44C > G c.C44G A15G c.53T > G c.T53G F18C c.58G > C c.G58C A20P c.59C > A c.C59A A20D c.70T > C or c.70T > A c.T70C or c.T70A W24R c.70T > G c.T70G W24G c.72G > C or c.72G > T c.G72C or c.G72T W24C c.95T > C c.T95C L32P c.97G > T c.G97T D33Y c.98A > G c.A98G D33G c.100A > G c.A100G N34D c.101A > C c.A101C N34T c.101A > G c.A101G N34S c.102T > G or c.102T > A c.T102G or c.T102A N34K c.103G > C or c.103G > A c.G103C or c.G103A G35R c.104G > A c.G104A G35E c.104G > T c.G104T G35V c.107T > C c.T107C L36S c.107T > G c.T107G L36W c.108G > C or c.108G > T c.G108C or c.G108T L36F c.109G > A c.G109A A37T c.110C > T c.C110T A37V c.122C > T c.C122T T41I c.124A > C or c.124A > T c.A124C or c.A124T M42L c.124A > G c.A124G M42V c.125T > A c.T125A M42K c.125T > C c.T125C M42T c.125T > G c.T125G M42R c.126G > A or c.126G > C or c.G126A or c.G126C or c.G126T M42I c.126G > T c.137A > C c.A137C H46P c.142G > C c.G142C E48Q c.152T > A c.T152A M51K c.153G > A or c.153G > T or c.G153A or c.G153T or c.G153C M51I c.153G > C c.157A > G c.A157G N53D c.[157A > C; 158A > T] c.A157C/A158T N53L c.160C > T c.C160T L54F c.161T > C c.T161C L54P c.164A > G c.A164G D55G c.164A > T c.A164T D55V c.[164A > T; 170A > T] c.A164T/A170T D55V/Q57L c.167G > T c.G167T C56F c.167G > A c.G167A C56Y c.170A > T c.A170T Q57L c.175G > A c.G175A E59K c.178C > A c.C178A P60T c.178C > T c.C178T P60S c.179C > T c.C179T P60L c.196G > A c.G196A E66K c.197A > G c.A197G E66G c.207C > A or c.207C > G c.C207A or c.C207G F69L c.214A > G c.A214G M72V c.216G > A or c.216G > T or c.G216A or c.G216T or c.G216C M72I c.216G > C c.218C > T c.C218T A73V c.227T > C c.T227C M76T c.239G > A c.G239A G80D c.247G > A c.G247A D83N c.253G > A c.G253A G85S c.254G > A c.G254A G85D c.[253G > A; 254G > A] c.G253A/G254A G85N c.[253G > A; 254G > T; 255T > G] c.G253A/G254T/T255G G85M c.261G > C or c.261G > T c.G261C or c.G261T E87D c.265C > T c.C265T L89F c.272T > C c.T272C I91T c.288G > A or c.288G > T or c.G288A or c.G288T or c.G288C M96I c.288G > C c.289G > C c.G289C A97P c.290C > T c.C290T A97V c.305C > T c.C305T S102L c.311G > T c.G311T G104V c.316C > T c.C316T L106F c.322G > A c.G322A A108T c.326A > G c.A326G D109G c.334C > G c.C334G R112G c.335G > A c.G335A R112H c.337T > A c.T337A F113I c.337T > C or c.339T > A or c.T337C or c.T339A or c.T339G F113L c.339T > G c.352C > T c.C352T R118C c.361G > A c.G361A A121T c.368A > G c.A368G Y123C c.373C > T c.C373T H125Y c.374A > T c.A374T H125L c.376A > G c.A376G S126G c.383G > A c.G383A G128E c.399T > G c.T399G I133M c.404C > T c.C404T A135V c.408T > A or c.408T > G c.T408A or c.T408G D136E c.416A > G c.A416G N139S c.419A > C c.A419C K140T c.427G > A c.G427A A143T c.431G > A c.G431A G144D c.431G > T c.G431T G144V c.434T > C c.T434C F145S c.436C > T c.C436T P146S c.437C > G c.C437G P146R c.454T > C c.T454C Y152H c.455A > G c.A455G Y152C c.466G > A c.G466A A156T c.467C > T c.C467T A156V c.471G > C or c.471G > T c.G471C or c.G471T Q157H c.484T > G c.T484G W162G c.493G > C c.G493C D165H c.494A > G c.A494G D165G c.[496C > G; 497T > G] c.C496G/T497G L166G c.496C > G c.C496G L166V c.496_497delinsTC c.496_497delinsTC L166S c.499C > G c.C499G L167V c.506T > C c.T506C F169S c.511G > A c.G511A G171S c.520T > C c.T520C C174R c.520T > G c.T520G C174G c.525C > G or c.525C > A c.C525G or c.C525A D175E c.539T > G c.T539G L180W c.540G > C c.G540C L180F c.548G > C c.G548C G183A c.548G > A c.G548A G183D c.550T > A c.T550A Y184N c.551A > G c.A551G Y184C c.553A > G c.A553G K185E c.559A > G c.A559G M187V c.559_564dup c.559_564dup p.M187_S188dup c.560T > C c.T560C M187T c.561G > T or c.561G > A or c.G561T or c.G561A or c.G561C M187I c.561G > C c.572T > A c.T572A L191Q c.581C > T c.C581T T194I c.584G > T c.G584T G195V c.586A > G c.A586G R196G c.593T > C c.T593C I198T c.595G > A c.G595A V199M c.596T > C c.T596C V199A c.596T > G c.T596G V199G c.599A > G c.A599G Y200C c.602C > T c.C602T S201F c.602C > A c.C602A S201Y c.608A > T c.A608T E203V c.609G > C or c.609G > T c.G609C or c.G609T E203D c.613C > A c.C613A P205T c.613C > T c.C613T P205S c.614C > T c.C614T P205L c.619T > C c.T619C Y207H c.620A > C c.A620C Y207S c.623T > G c.T623G M208R c.628C > T c.C628T P210S c.629C > T c.C629T P210L c.638A > G c.A638G K213R c.638A > T c.A638T K213M c.640C > T c.C640T P214S c.641C > T c.C641T P214L c.643A > G c.A643G N215D c.644A > G c.A644G N215S c.644A > T c.A644T N215I c.[644A > G; 937G > T] c.A644G/G937T N215S/D313Y c.646T > G c.T646G Y216D c.647A > G c.A647G Y216C c.655A > C c.A655C I219L c.656T > A c.T656A I219N c.656T > C c.T656C I219T c.659G > A c.G659A R220Q c.659G > C c.G659C R220P c.662A > C c.A662C Q221P c.671A > C c.A671C N224T c.671A > G c.A671G N224S c.673C > G c.C673G H225D c.683A > G c.A683G N228S c.687T > A or c.687T > G c.T687A or c.T687G F229L c.695T > C c.T695C I232T c.713G > A c.G713A S238N c.716T > C c.T716C I239T c.720G > C or c.720G > T c.G720C or c.G720T K240N c.724A > G c.A724G I242V c.724A > T c.A724T I242F c.725T > A c.T725A I242N c.725T > C c.T725C I242T c.728T > G c.T728G L243W c.729G > C or c.729G > T c.G729C or c.G729T L243F c.730G > A c.G730A D244N c.730G > C c.G730C D244H c.733T > G c.T733G W245G c.740C > G c.C740G S247C c.747C > G or c.747C > A c.C747G or c.C747A N249K c.749A > C c.A749C Q250P c.749A > G c.A749G Q250R c.750G > C c.G750C Q250H c.758T > C c.T758C I253T c.758T > G c.T758G I253S c.760-762delGTT c.760_762delGTT p.V254del c.769G > C c.G769C A257P c.770C > G c.C770G A257G c.772G > C or c.772G > A c.G772C or c.G772A G258R c.773G > T c.G773T G258V c.776C > G c.C776G P259R c.776C > T c.C776T P259L c.779G > A c.G779A G260E c.779G > C c.G779C G260A c.781G > A c.G781A G261S c.781G > C c.G781C G261R c.781G > T c.G781T G261C c.788A > G c.A788G N263S c.790G > T c.G790T D264Y c.794C > T c.C794T P265L c.800T > C c.T800C M267T c.805G > A c.G805A V269M c.806T > C c.T806C V269A c.809T > C c.T809C I270T c.810T > G c.T810G I270M c.811G > A c.G811A G271S c.[811G > A; 937G > T] c.G811A/G937T G271S/D313Y c.812G > A c.G812A G271D c.823C > G c.C823G L275V c.827G > A c.G827A S276N c.829T > G c.T829G W277G c.831G > T or c.831G > C c.G831T or c.G831C W277C c.832A > T c.A832T N278Y c.835C > G c.C835G Q279E c.838C > A c.C838A Q280K c.840A > T or c.840A > C c.A840T or c.A840C Q280H c.844A > G c.A844G T282A c.845C > T c.C845T T282I c.850A > G c.A850G M284V c.851T > C c.T851C M284T c.860G > T c.G860T W287L c.862G > C c.G862C A288P c.866T > G c.T866G I289S c.868A > C or c.868A > T c.A868C or c.A868T M290L c.869T > C c.T869C M290T c.870G > A or c.870G > C or c.G870A or c.G870C or c.G870T M290I c.870G > T c.871G > A c.G871A A291T c.877C > A c.C877A P293T c.881T > C c.T881C L294S c.884T > G c.T884G F295C c.886A > G c.A886G M296V c.886A > T or c.886A > C c.A886T or c.A886C M296L c.887T > C c.T887C M296T c.888G > A or c.888G > T or c.G888A or c.G888T or c.G888C M296I c.888G > C c.893A > G c.A893G N298S c.897C > G or c.897C > A c.C897G or c.C897A D299E c.898C > T c.C898T L300F c.899T > C c.T899C L300P c.901C > G c.C901G R301G c.902G > C c.G902C R301P c.902G > A c.G902A R301Q c.902G > T c.G902T R301L c.907A > T c.A907T I303F c.908T > A c.T908A I303N c.911G > A c.G911A S304N c.911G > C c.G911C S304T c.919G > A c.G919A A307T c.922A > G c.A922G K308E c.924A > T or c.924A > C c.A924T or c.A924C K308N c.925G > C c.G925C A309P c.926C > T c.C926T A309V c.928C > T c.C928T L310F c.931C > G c.C931G L311V c.935A > G c.A935G Q312R c.936G > T or c.936G > C c.G936T or c.G936C Q312H c.937G > T c.G937T D313Y c.[937G > T; 1232G > A] c.G937T/G1232A D313Y/G411D c.938A > G c.A938G D313G c.946G > A c.G946A V316I c.947T > G c.T947G V316G c.950T > C c.T950C I317T c.955A > T c.A955T I319F c.956T > C c.T956C I319T c.959A > T c.A959T N320I c.962A > G c.A962G Q321R c.962A > T c.A962T Q321L c.963G > C or c.963G > T c.G963C or c.G963T Q321H c.964G > A c.G964A D322N c.964G > C c.G964C D322H c.966C > A or c.966C > G c.C966A or c.C966G D322E c.968C > G c.C968G P323R c.973G > A c.G973A G325S c.973G > C c.G973C G325R c.978G > C or c.978G > T c.G978C or c.G978T K326N c.979C > G c.C979G Q327E c.980A > T c.A980T Q327L c.983G > C c.G983C G328A c.989A > G c.A989G Q330R c.1001G > A c.G1001A G334E c.1010T > C c.T1010C F337S c.1012G > A c.G1012A E338K c.1016T > A c.T1016A V339E c.1027C > A c.C1027A P343T c.1028C > T c.C1028T P343L c.1033T > C c.T1033C S345P c.1046G > C c.G1046C W349S c.1055C > G c.C1055G A352G c.1055C > T c.C1055T A352V c.1061T > A c.T1061A I354K c.1066C > G c.C1066G R356G c.1066C > T c.C1066T R356W c.1067G > A c.G1067A R356Q c.1067G > C c.G1067C R356P c.1072G > C c.G1072C E358Q c.1073A > C c.A1073C E358A c.1073A > G c.A1073G E358G c.1074G > T or c.1074G > C c.G1074T or c.G1074C E358D c.1076T > C c.T1076C I359T c.1078G > A c.G1078A G360S c.1078G > T c.G1078T G360C c.1079G > A c.G1079A G360D c.1082G > A c.G1082A G361E c.1082G > C c.G1082C G361A c.1084C > A c.C1084A P362T c.1085C > T c.C1085T P362L c.1087C > T c.C1087T R363C c.1088G > A c.G1088A R363H c.1102G > A c.G1102A A368T c.1117G > A c.G1117A G373S c.1124G > A c.G1124A G375E c.1153A > G c.A1153G T385A c.1168G > A c.G1168A V390M c.1172A > C c.A1172C K391T c.1184G > A c.G1184A G395E c.1184G > C c.G1184C G395A c.1192G > A c.G1192A E398K c.1202_1203insGACTTC c.1202_1203insGACTTC p.T400_S401dup c.1208T > C c.T1208C L403S c.1225C > G c.C1225G P409A c.1225C > T c.C1225T P409S c.1225C > A c.C1225A P409T c.1228A > G c.A1228G T410A c.1229C > T c.C1229T T410I c.1232G > A c.G1232A G411D c.1235C > A c.C1235A T412N c.1253A > G c.A1253G E418G c.1261A > G c.A1261G M421V

Dosing, Formulation and Administration

In one or more embodiments, the Fabry patient is administered migalastat or salt thereof at a frequency of once every other day (also referred to as “QOD”). In various embodiments, the doses described herein pertain to migalastat hydrochloride or an equivalent dose of migalastat or a salt thereof other than the hydrochloride salt. In some embodiments, these doses pertain to the free base of migalastat. In alternate embodiments, these doses pertain to a salt of migalastat. In further embodiments, the salt of migalastat is migalastat hydrochloride. The administration of migalastat or a salt of migalastat is referred to herein as “migalastat therapy”.

It is noted that 150 mg of migalastat hydrochloride is equivalent to 123 mg of the free base form of migalastat. Thus, in one or more embodiments, the dose is 150 mg of migalastat hydrochloride or an equivalent dose of migalastat or a salt thereof other than the hydrochloride salt, administered at a frequency of once every other day. As set forth above, this dose is referred to as 123 mg FBE of migalastat. In further embodiments, the dose is 150 mg of migalastat hydrochloride administered every other day. In other embodiments, the dose is 123 mg of the migalastat free base administered at a frequency of once every other day.

Accordingly, in various embodiments, migalastat therapy includes administering 123 mg FBE every other day, such as 150 mg of migalastat hydrochloride every other day.

The administration of migalastat may be for a certain period of time. In one or more embodiments, the migalastat is administered for at least 28 days, such as at least 30, 60 or 90 days or at least 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 16, 20, 24, 30 or 36 months or at least 1, 2, 3, 4 or 5 years. In various embodiments, the migalastat therapy is long-term migalastat therapy of at least 6 months, such as at least 6, 7, 8, 9, 10, 11, 12, 16, 20, 24, 30 or 36 months or at least 1, 2, 3, 4 or 5 years.

Administration of migalastat according to the present invention may be in a formulation suitable for any route of administration, but is preferably administered in an oral dosage form such as a tablet, capsule or solution. As one example, the patient is orally administered capsules each containing 150 mg migalastat hydrochloride or an equivalent dose of migalastat or a salt thereof other than the hydrochloride salt.

In some embodiments, the PC (e.g., migalastat or salt thereof) is administered orally. In one or more embodiments, the PC (e.g., migalastat or salt thereof) is administered by injection. The PC may be accompanied by a pharmaceutically acceptable carrier, which may depend on the method of administration.

In one embodiment of the invention, the PC (e.g., migalastat or salt thereof) is administered as monotherapy, and can be in a form suitable for any route of administration, including e.g., orally in the form tablets or capsules or liquid, in sterile aqueous solution for injection, or in a dry lyophilized powder to be added to the formulation of the replacement enzyme during or immediately after reconstitution to prevent enzyme aggregation in vitro prior to administration.

When the PC (e.g., migalastat or salt thereof) is formulated for oral administration, the tablets or capsules can be prepared by conventional means with pharmaceutically acceptable excipients such as binding agents (e.g., pregelatinized maize starch, polyvinylpyrrolidone or hydroxypropyl methylcellulose); fillers (e.g., lactose, microcrystalline cellulose or calcium hydrogen phosphate); lubricants (e.g., magnesium stearate, talc or silica); disintegrants (e.g., potato starch or sodium starch glycolate); or wetting agents (e.g., sodium lauryl sulfate). The tablets may be coated by methods well known in the art. Liquid preparations for oral administration may take the form of, for example, solutions, syrups or suspensions, or they may be presented as a dry product for constitution with water or another suitable vehicle before use. Such liquid preparations may be prepared by conventional means with pharmaceutically acceptable additives such as suspending agents (e.g., sorbitol syrup, cellulose derivatives or hydrogenated edible fats); emulsifying agents (e.g., lecithin or acacia); non-aqueous vehicles (e.g., almond oil, oily esters, ethyl alcohol or fractionated vegetable oils); and preservatives (e.g., methyl or propyl-p-hydroxybenzoates or sorbic acid). The preparations may also contain buffer salts, flavoring, coloring and sweetening agents as appropriate. Preparations for oral administration may be suitably formulated to give controlled release of the active chaperone compound.

The pharmaceutical formulations of the PC (e.g., migalastat or salt thereof) suitable for parenteral/injectable use generally include sterile aqueous solutions (where water soluble), or dispersions and sterile powders for the extemporaneous preparation of sterile injectable solutions or dispersion. In all cases, the form must be sterile and must be fluid to the extent that easy syringability exists. It must be stable under the conditions of manufacture and storage and must be preserved against the contaminating action of microorganisms such as bacteria and fungi. The carrier can be a solvent or dispersion medium containing, for example, water, ethanol, polyol (for example, glycerol, propylene glycol, and polyethylene glycol, and the like), suitable mixtures thereof, and vegetable oils. The proper fluidity can be maintained, for example, by the use of a coating such as lecithin, by the maintenance of the required particle size in the case of dispersion and by the use of surfactants. Prevention of the action of microorganisms can be brought about by various antibacterial and antifungal agents, for example, parabens, chlorobutanol, phenol, benzyl alcohol, sorbic acid, and the like. In many cases, it will be reasonable to include isotonic agents, for example, sugars or sodium chloride. Prolonged absorption of the injectable compositions can be brought about by the use in the compositions of agents delaying absorption, for example, aluminum monosterate and gelatin.

Sterile injectable solutions are prepared by incorporating the purified enzyme (if any) and the PC (e.g., migalastat or salt thereof) in the required amount in the appropriate solvent with various of the other ingredients enumerated above, as required, followed by filter or terminal sterilization. Generally, dispersions are prepared by incorporating the various sterilized active ingredients into a sterile vehicle which contains the basic dispersion medium and the required other ingredients from those enumerated above. In the case of sterile powders for the preparation of sterile injectable solutions, the preferred methods of preparation are vacuum drying and the freeze-drying technique which yield a powder of the active ingredient plus any additional desired ingredient from previously sterile-filtered solution thereof.

The formulation can contain an excipient. Pharmaceutically acceptable excipients which may be included in the formulation are buffers such as citrate buffer, phosphate buffer, acetate buffer, and bicarbonate buffer, amino acids, urea, alcohols, ascorbic acid, phospholipids; proteins, such as serum albumin, collagen, and gelatin; salts such as EDTA or EGTA, and sodium chloride; liposomes; polyvinylpyrollidone; sugars, such as dextran, mannitol, sorbitol, and glycerol; propylene glycol and polyethylene glycol (e.g., PEG-4000, PEG-6000); glycerol; glycine or other amino acids; and lipids. Buffer systems for use with the formulations include citrate; acetate; bicarbonate; and phosphate buffers. Phosphate buffer is a preferred embodiment.

The route of administration of the chaperone compound may be oral or parenteral, including intravenous, subcutaneous, intra-arterial, intraperitoneal, ophthalmic, intramuscular, buccal, rectal, vaginal, intraorbital, intracerebral, intradermal, intracranial, intraspinal, intraventricular, intrathecal, intracisternal, intracapsular, intrapulmonary, intranasal, transmucosal, transdermal, or via inhalation.

Administration of the above-described parenteral formulations of the chaperone compound may be by periodic injections of a bolus of the preparation, or may be administered by intravenous or intraperitoneal administration from a reservoir which is external (e.g., an i.v. bag) or internal (e.g., a bioerodable implant).

Embodiments relating to pharmaceutical formulations and administration may be combined with any of the other embodiments of the invention, for example embodiments relating to methods of treating patients with Fabry disease, methods of treating ERT-naïve Fabry patients, methods of treating ERT-experienced Fabry patients, methods of reducing LVM, methods of reducing LVMi, methods of normalizing LVMi, methods of reducing podocyte GL-3, methods of reducing podocyte volume, methods of reducing GL-3 inclusion volume in podocytes, methods of enhancing α-Gal A in a patient diagnosed with or suspected of having Fabry disease, use of a pharmacological chaperone for α-Gal A for the manufacture of a medicament for treating a patient diagnosed with Fabry disease or to a pharmacological chaperone for α-Gal A for use in treating a patient diagnosed with Fabry disease as well as embodiments relating to amenable mutations, the PCs and suitable dosages thereof.

In one or more embodiments, the PC (e.g., migalastat or salt thereof) is administered in combination with ERT. ERT increases the amount of protein by exogenously introducing wild-type or biologically functional enzyme by way of infusion. This therapy has been developed for many genetic disorders, including lysosomal storage disorders such as Fabry disease, as referenced above. After the infusion, the exogenous enzyme is expected to be taken up by tissues through non-specific or receptor-specific mechanism. In general, the uptake efficiency is not high, and the circulation time of the exogenous protein is short. In addition, the exogenous protein is unstable and subject to rapid intracellular degradation as well as having the potential for adverse immunological reactions with subsequent treatments. In one or more embodiments, the chaperone is administered at the same time as replacement enzyme (e.g., replacement α-Gal A). In some embodiments, the chaperone is co-formulated with the replacement enzyme (e.g., replacement α-Gal A).

In one or more embodiments, a patient is switched from ERT to migalastat therapy. In some embodiments, a patient on ERT is identified, the patient's ERT is discontinued, and the patient begins receiving migalastat therapy. The migalastat therapy can be in accordance with any of the methods described herein.

Left Ventricular Mass

The dosing regimens described herein can improve LVM or LVMi in Fabry patients. The natural history of LVMi and cardiac hypertrophy in untreated Fabry patients regardless of phenotype (Patel, O'Mahony et al. 2015) is a progressive increase in LVMi between +4.07 and +8.0 g/m²/year (Kampmann, Linhart et al. 2008; Wyatt, Henley et al. 2012; Germain, Weidemann et al. 2013). As untreated Fabry patients typically exhibit an increase in LVMi over time, both decreases in and maintenance of LVMi are indications of a benefit of migalastat therapy. As described in further detail in the Examples below, Phase 3 studies have found that migalastat therapy decreases LVMi in both ERT-experienced and ERT-naïve patients, with even greater reductions in LVMi shown in patients with LVH at baseline. These Phase 3 studies also found that migalastat therapy normalizes LVMi in some patients with LVH. Accordingly, migalastat therapy can be used to treat Fabry patients by reducing LVM, reducing LVMi and/or normalizing LVMi in ERT-naïve and/or ERT-experienced Fabry patients, including patients with LVH.

The Phase 3 studies of migalastat therapy evaluated LVMi, which is considered a more accurate measure than LVM. Also, in the Phase 3 studies, the echocardiograms were conducted locally, but the echocardiograms were all centrally read by the same reader. Using the same reader to centrally read the echocardiograms improves accuracy compared to reading the echocardiograms locally.

The migalastat therapy may reduce the increase in LVMi for a Fabry patient compared to the same patient without treatment with migalastat therapy. In one or more embodiments, the migalastat therapy provides a change in LVMi for a patient that is less than (i.e., more negative than) 0 g/m², such as less than or equal to about −0.5, −1, −1.5, −2, −2.5, −3, −3.5, −4, −4.5, −5, −5.5, −6, −7, −8, −9, −10, −11, −12, −13, −14, −15, −16, −17, −18, −19 or −20 g/m². Expressed differently, in one or more embodiments, the migalastat therapy provides a reduction in LVMi of greater than 0 g/m², such as reductions of at least about 0.5, 1, 1.5, 2, 2.5, 3, 3.5, 4, 4.5, 5, 5.5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 or 20 g/m².

In one or more embodiments, the migalastat therapy provides an average decrease of LVMi in a group of ERT-experienced patients of at least about 1 g/m² after 18 months of administration of migalastat or a salt thereof. In various embodiments, the average decrease in the group of ERT-experienced patients after 18 months of administration of migalastat or a salt thereof is at least about 1, 2, 3, 4, 5 or 6 g/m², such as about 6.6 g/m².

In one or more embodiments, the migalastat therapy provides an average decrease of LVMi in a group of ERT-experienced patients of at least about 1 g/m² after 18 months of administration of migalastat or a salt thereof. In various embodiments, the average decrease in the group of ERT-experienced patients after 18 months of administration of migalastat or a salt thereof is at least about 1, 2, 3, 4, 5, 6, 7 or 8 g/m², such as about 8.4 g/m².

In one or more embodiments, the migalastat therapy provides an average decrease of LVMi in a group of ERT-experienced patients of at least about 0.5 g/m² after 30 months of administration of migalastat or a salt thereof. In various embodiments, the average decrease in the group of ERT-experienced patients after 30 months of administration of migalastat or a salt thereof is at least about 0.5, 1, 1.5, 2, 2.5, 3, 3.5 or 4 g/m², such as about 3.8 g/m².

In one or more embodiments, the migalastat therapy provides an average decrease of LVMi in a group of ERT-experienced patients with LVH of at least about 1 g/m² after 30 months of administration of migalastat or a salt thereof. In various embodiments, the average decrease in the group of ERT-experienced patients with LVH after 30 months of administration of migalastat or a salt thereof is at least about 1, 2, 3, 4, 5, 6, 8, 8 or 9 g/m², such as about 9 g/m².

In one or more embodiments, the migalastat therapy provides an average decrease of LVMi in a group of ERT-naïve patients of at least about 1 g/m² after 18 to 24 months of administration of migalastat or a salt thereof. In various embodiments, the average decrease in the group of ERT-naïve patients after 18 to 24 months of administration of migalastat or a salt thereof is at least about 1, 2, 3, 4, 5, 6 or 7 g/m², such as about 7.7 g/m².

In one or more embodiments, the migalastat therapy provides an average decrease of LVMi in a group of ERT-naïve patients with LVH of at least about 1 g/m² after 18 to 24 months of administration of migalastat or a salt thereof. In various embodiments, the average decrease in the group of ERT-naïve with LVH patients after 18 to 24 months of administration of migalastat or a salt thereof is at least about 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17 or 18 g/m², such as about 18.6 g/m².

In one or more embodiments, the migalastat therapy provides an average decrease of LVMi in a group of ERT-naïve patients of at least about 1 g/m² after 30 to 36 months of administration of migalastat or a salt thereof. In various embodiments, the average decrease in the group of ERT-naïve patients after 30 to 36 months of administration of migalastat or a salt thereof is at least about 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 or 17 g/m², such as about 17 g/m².

In one or more embodiments, the migalastat therapy provides an average decrease of LVMi in a group of ERT-naïve patients with LVH of at least about 1 g/m² after 30 to 36 months of administration of migalastat or a salt thereof. In various embodiments, the average decrease in the group of ERT-naïve patients with LVH after 30 to 36 months of administration of migalastat or a salt thereof is at least about 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 or 20 g/m², such as about 20.8 g/m².

Podocyte GL-3 and Podocyte Volume

The dosing regimens described herein can improve one or more parameters related to podocytes in Fabry patients. Fabry patients typically accumulate GL-3 in podocyte cells. As described in further detail in the Examples below, a Phase 3 study has found that migalastat therapy reduces mean podocyte volume and reduces mean podocyte GL-3 inclusion volume. Accordingly, migalastat therapy can be used to treat Fabry patients by reducing podocyte GL-3, reducing podocyte volume and/or reducing GL-3 inclusion volume in podocytes.

The Phase 3 study of migalastat therapy evaluated podocyte GL-3 according to two methodologies. In the first methodology, a qualitative comparison of GL-3 for podocytes was performed, as a reliable quantitative approach was not available at the time of this study. The pathologists assessed side-by-side digital images of baseline and post-baseline biopsies (blinded to treatment assignment and visit date), and categorized the biopsies as having more, less or equal GL-3 in the podocytes. Of note, if a score of either more or less GL-3 was assigned, then this indicates that there was a visually apparent change in GL-3 between baseline and post-baseline. Three pathologists determined in a blinded fashion whether paired biopsies had an “equal” number of GL-3 inclusions within each cell type, or whether one in the pair had “less” or “more” inclusions. If 2 pathologists agreed on “less” or “more” that agreed value was assigned, otherwise a designation of “equal” was retained. Results were summarized as percent of specimens with increases, decreases, or no change in GL-3 inclusions relative to baseline.

In the second methodology, a post-hoc analysis was performed using stereological principles to estimate structural parameters including average podocyte volume, fractional volume of GL-3 inclusions within podocytes, and total volume of GL-3 inclusions per podocyte. These stereological principles, which are based on stochastic geometry and statistics, are designed to be unbiased, efficient, and reproducible. Electron microscopic images (˜30,000×), taken according to a systematic, unbiased, uniform random sampling method from glomeruli were used to estimate fractional volume (Vv) of GL-3 inclusions in podocytes [Vv(Inc/PC)]. Grids with appropriate point densities were superimposed over the images. The parameters were calculated by dividing the number of grid points hitting GL-3 inclusions by the number of grid points hitting cytoplasm of glomerular podocytes.

In one or more embodiments, the migalastat therapy may reduce the podocyte volume for a Fabry patient compared to the same patient without treatment with migalastat therapy. In one or more embodiments, the migalastat therapy reduces the podocyte volume by at least about 10%, such as at least about 15, 20, 25, 30, 35, 40, 45 or 50%.

In one or more embodiments, the migalastat therapy provides an average reduction of podocyte volume in a group of ERT-naïve patients of at least about 10% after 6 months of administration of migalastat or a salt thereof. In various embodiments, the average reduction in the group of ERT-naïve patients after 6 months of administration of migalastat or a salt thereof is at least about 10, 15, 20, 25, 30, 35, 40, 45 or 50%, such as about 47%.

In one or more embodiments, the migalastat therapy may reduce the total GL-3 inclusion volume per podocyte for a Fabry patient compared to the same patient without treatment with migalastat therapy. In one or more embodiments, the migalastat therapy reduces the podocyte GL-3 inclusion volume by at least about 10%, such as at least about 15, 20, 25, 30, 35, 40, 45 or 50%.

In one or more embodiments, the migalastat therapy provides an average reduction of total GL-3 inclusion volume per podocyte in a group of ERT-naïve patients of at least about 10% after 6 months of administration of migalastat or a salt thereof. In various embodiments, the average reduction in the group of ERT-naïve patients after 6 months of administration of migalastat or a salt thereof is at least about 10, 15, 20, 25, 30, 35, 40, 45 or 50%, such as about 50%.

EXAMPLES Example 1: Dosing Regimens for the Treatment of ERT-Naïve Fabry Patients Using Migalastat Hydrochloride

This example describes a Phase 3 study of migalastat therapy in ERT-naïve Fabry patients.

Patient Enrollment.

Eligible patients were 16-74 years old and had genetically-confirmed Fabry disease; had either never received or had not received ERT for ≥6 months; had a GLA mutation that resulted in a mutant protein that would respond to migalastat, based on the human embryonic kidney-293 (HEK) assay used at the time of enrollment; had an eGFR >30 ml/minute/1.73 m², and had a urinary GL-3≥4 times the upper limit of normal.

Study Design.

Following eligibility-baseline assessments (2 months), patients were randomized to Stage 1—6 months of double-blind administration of 150 mg migalastat hydrochloride or placebo every other day. All patients completing Stage 1 were eligible to receive open-label migalastat in Stage 2 (months 6-12) and for an additional year (months 13-24) thereafter. The primary objective was to compare the effect of migalastat to placebo on kidney GL-3 as assessed by histological scoring of the number of inclusions in interstitial capillaries after 6 months of treatment. The secondary objectives of Stage 1 were to compare the effect of migalastat to placebo on urine GL-3 levels, on renal function, 24-hours urinary protein, and on safety and tolerability. The tertiary objectives were cardiac function, patient-reported outcomes, exploratory kidney analyses, and white blood cell α-Gal A activity. Study completers were eligible to enroll in the open-label extension study for up to 5 years.

Kidney Histology Assessment.

Each patient underwent a baseline kidney biopsy, as well as repeat kidney biopsies at 6 and 12 months. The number of GL-3 inclusions per kidney interstitial capillary per patient at baseline, and at 6 and 12 months was quantitatively assessed in 300 capillaries by 3 independent pathologists blinded to treatment and visit. All values for each individual biopsy at a given time were averaged prior to statistical analysis.

GL-3 changes in podocytes, endothelial cells, and mesangial cells, and glomerular sclerosis, were assessed qualitatively by the same 3 pathologists blinded to treatment/visit.

Globotriaosylceramide and Globotriaosylsphingosine.

Plasma lyso-Gb3 and 24-hour urine GL-3 were analyzed by liquid chromatography-mass-spectroscopy using a novel stable isotope-labeled internal standard, 13C6-lyso-Gb3 (lower-limit-of-quantification: 0.200 ng/mL, 0.254 nmol/L).

Renal Function Assessment.

Annualized rates of change (mL/min/1.73 m²/year) were calculated using Chronic Kidney Disease Epidemiology Collaboration-eGFR_(CKD-EPI)) and measured iohexol clearance-mGFR_(iohexol)).

Echocardiography.

LVMi, left posterior wall thickness, diastolic, interventricular septum thickness, diastolic and other parameters were assessed through blinded, centralized evaluation.

Patient-Reported Outcomes.

Patient-reported outcomes were assessed using the Gastrointestinal-Symptoms-Rating-Scale (GSRS), Short Form-36v2™ and Brief-Pain-Inventory-Pain-Severity-Component.

Safety Analysis and Adverse Events.

Randomized patients receiving ≥1 dose were included in the safety analysis, which comprised vital signs, physical exams, electrocardiograms, clinical labs, and adverse events.

Statistical Analyses for Kidney Interstitial Capillary GL-3 Substrate.

The primary Stage 1 (6 month) endpoint (ITT population with baseline biopsies, n=64) was the proportion of patients in the migalastat and placebo groups with a ≥50% reduction in GL-3 inclusions per interstitial capillary. Two other Stage 1 endpoints were assessed (modified-ITT population: randomized patients with paired baseline and month 6 biopsies; n=60): percent change in GL-3 inclusions per interstitial capillary, and percent of interstitial capillaries with zero GL-3 inclusions.

Efficacy analyses for GL-3 inclusions per interstitial capillary and other prespecified endpoints in Stage 2 (months 6-12) and the open-label-extension (months 12-24) were based on the modified intention to treat (mITT)—population consisting of randomized patients with mutant α-Gal A enzyme shown to be suitable for migalastat treatment by the validated assay; n=50).

Results

Baseline Characteristics.

Sixty-seven patients (16-74 years-old; 64% female) with potentially responsive mutant α-Gal A were randomized (ITT population). Table 2 provides the baseline characteristics for the 50 patients in the ITT population with suitable mutant α-Gal A. There were no statistically significant differences in baseline parameters.

TABLE 2 Baseline Characteristics Treatment Group Placebo to Migalastat HCl Migalastat HCl Total Parameter (N = 28) (N = 22) (N = 50) Age (year) (n) 28 22 50 Mean ± SD 41.5 ± 13   45.1 ± 8.0  43.1 ± 11   Median 37.0 45.5 45.0 Weight (kg) (n) 28 22 50 Mean ± SD 72.6 ± 15.35 76.1 ± 16.52 74.1 ± 15.81 Median 72.3 74.0 72.8 Number of Years of Diagnosis of 28 21 49 Fabry Disease (n) Mean ± SD 5.6 ± 6.89 7.3 ± 8.80 6.3 ± 7.73 Median 4.1 4.1 4.1 Number of patients previously on 4 (14.3%) 7 (31.8%) 11 (22.0%) ERT (>6 months prior to baseline) (%) Use of ACEi/ARB/Ri at Baseline Yes (%) 9 (32.1%) 12 (54.5%) 21 (42.0%) No (%) 19 (67.9%)  10 (45.5%) 29 (58.0%) Proteinuria > 150 mg/24 h (%) 17 (60.7%)  18 (81.8%) 35 (70.0%) Proteinuria > 300 mg/24 h (%) 8 (28.6%) 11 (50.0%) 19 (38.0%) Proteinuria > 1000 mg/24 h (%) 3 (10.7%)  3 (13.6%)  6 (12.0%) mGFR_(Iohexol) (mL/min/1.73 m²) (n) 27 21 48 Mean ± SD 79.95 ± 30.9  83.12 ± 22.8  81.34 ± 27.5  Median 84.90 82.20 83.40 eGFR_(CKD-EPI) (mL/min/1.73 m²) 28 22 50 Mean ± SD 94.4 ± 27.0  90.6 ± 17.1  92.7 ± 23.0  Median 96.6 93.5 94.0 Lyso-Gb₃ (n) 18 13 31 Mean (nmol/L) ± SD 47.3 ± 62   41.9 ± 39   45.0 ± 53  

Published reports of clinical phenotype(s) associated with the genotypes of patients with suitable mutations (n=50) indicate that 30 (60%) had mutations associated with the classic phenotype of Fabry disease, one (2%) with the non-classic phenotype, three (6%) with both phenotypes, and 16 (32%) not yet classified. Residual WBC α-Gal A activity <3% was found in 14 of 16 (87%) males; 29 of 31 (94%) males and females had elevated plasma lyso-Gb3, and 47 of 50 (94%) males and females had multi-organ system disease.

Migalastat and Kidney Interstitial Capillary GL-3.

In the 6-month primary outcome analysis (ITT), 13 of 32 (41%) migalastat and 9 of 32 (28%) placebo-treated patients achieved a response (≥50% reduction in GL-3 inclusions per interstitial capillary) (p=0.30). The median change in interstitial capillary GL-3 from baseline was −40.8% for migalastat versus −5.59% for placebo (p=0.097). The mean difference for the change in % of interstitial capillaries with zero GL-3 inclusions was 7.3% in favor of migalastat (p=0.042).

In Stage 1 (6-month post hoc) and Stage 2 (12-month prespecified) analyses (mITT-suitable population; n=45), 6 months of migalastat was associated with a significantly greater reduction in interstitial capillary GL-3 (±SEM) compared to placebo: −0.250±0.103 versus +0.071±0.126; p=0.008. The reduction in interstitial capillary GL-3 at 6 months remained stable following an additional 6 months of treatment. A significant reduction in interstitial capillary GL-3 (±SEM) was observed at 12 months in patients switching from placebo to migalastat at 6 months (−0.330±0.152; p=0.014). Patients with mutant α-Gal A that was not suitable for migalastat therapy according to the validated assay did not show any treatment effect in interstitial capillary GL-3.

Migalastat and GL-3 in Glomerular Cells.

Based on qualitative assessments on 23 kidney biopsies, following 12 months of migalastat, patients with responsive mutant α-Gal A showed decreases in glomerular podocyte (5 of 23 biopsies; 22%), endothelial cell (6 of 23 biopsies; 26%), and mesangial cell GL-3 (11 of 23 biopsies; 48%). None of the samples had increases; the remaining samples showed no change.

Migalastat and Plasma Lyso-Gb3 Levels.

Six months of migalastat (mITT-suitable) was associated with a significant reduction in plasma lyso-Gb3 levels compared to placebo (p=0.0033). Plasma lyso-Gb3 remained stable without further reduction following 6 additional months of migalastat. A significant reduction in plasma lyso-Gb3 was found in patients (ITT-suitable) switching from placebo to migalastat between 6 and 12 months (p<0.0001). Plasma levels in patients with mutant α-Gal A that was not suitable were unchanged.

Migalastat and Urine GL-3 Substrate.

In patients with suitable mutant α-Gal A, mean changes in 24-hour urine GL-3 substrate (±SEM) concentration for migalastat and placebo (baseline to month 6) were: −361±169 (to 555±151) and −147±217 (to 1017±218) ng/mg creatinine, respectively (p=0.44).

Migalastat and Kidney Function.

There were no statistically significant differences between the migalastat and placebo arms in eGFR_(CKD-EPI), or mGFR_(iohexol) changes from baseline to month 6 (mITT-suitable).

In patients followed for up to 24 months of migalastat (mITT-suitable), the annualized changes in eGFR_(CKD-EPI), and mGFR_(iohexol) (±SEM) were −0.30±6.6, and −1.51±1.33 mL/min/1.73 m², respectively. Male gender and higher baseline proteinuria were associated with higher rate of annual decline. There were no statistically significant differences in baseline levels or changes from baseline between treatment groups for 24-hour urine protein.

Migalastat and Echocardiographic Parameters.

At baseline, left-ventricular-mass-index was comparable between groups with no significant differences in Stage 1.

In patients (ITT-suitable), who received migalastat for up to 24 months, a statistically significant decrease in left-ventricular-mass-index (LVMi) (p<0.05 based on the 95% CI not including 0) was observed overall with a trend toward a larger reduction in patients with baseline LV hypertrophy. Table 3 shows the echocardiographic-derived LVMi changes from baseline to month 18/24 for ITT-suitable patients.

TABLE 3 LVMi Changes (ITT-Suitable) Patients Change from Baseline with Suitable Baseline² to Month 18/24³ Mutant α-Gal A¹ Mean ± SEM (g/m²) Mean ± SEM (95% CI) All  96.5 ± 5.0 −7.69 ± 3.7 (−15.4, −0.009)⁴ n = 44 n = 27 Patients with LVH 138.9 ± 11 −18.6 ± 8.3 (−38.2, 1.04) at baseline n = 11 n = 8 LVMi, Left-ventricular-mass-index (g/m²): Normal: 43-95 (female), 49-115 (male); ¹Includes patients with a baseline and post-baseline ECHO, who received ≥18-months migalastat. ²Month 6 used as baseline for placebo patients switching to migalastat; Baseline used if no month 6. ³Baseline of extension study used as month 18/24. ⁴Statistically significantly different from baseline based on 95% CIs not overlapping with 0; p < 0.05

Interventricular septal wall thickness decreased by 0.061 cm±0.051 (5.2%) from baseline (1.17 cm±0.057) (95% CI: −1.67, 0.045); the left ventricular posterior wall thickness was stable for up to 24 months. The changes in left-ventricular-mass-index correlated with changes in IVSWT (R²=0.26, p=0.006) but not with changes in left ventricular posterior wall thickness (R²=0.06, p=0.230).

LVMi continued to decrease over 30/36 months of migalastat treatment in an extension of this study, with mean change from baseline of −17.0 g/m² ([95% CI −26.2, −7.9]; n=15)]. In patients with baseline LVH (n=11), the change from baseline was larger and statistically, −20.8 g/m² [−95% CI −57.9, −2.2]. The LVMi changes from baseline to after 6/12, 18/24 and 30/36 months of migalastat therapy are shown in FIG. 3. In the extension of the study to 30/36 months, 82% (9/11) and 46% (5/11) of the patients with LVH at baseline had reductions and normalizations of LVMi, respectively.

Gastrointestinal Symptoms Rating Scale.

Gastrointestinal symptoms improved in 3 of 5 domains (diarrhea, reflux, indigestion) in migalastat-treated ITT-suitable patients, as shown in Table 4 below.

For the diarrhea domain, between baseline and month 6 (Stage 1), there was a statistically significant decrease (p=0.03; ITT-suitable); a nonsignificant decrease was also observed for ITT-suitable patients with baseline symptoms (p=0.06). Statistically significant changes over 24 months were found for ITT-suitable patients and ITT-suitable patients with baseline symptoms (p<0.05, based on the 95% CI not including 0).

There was a statistically significant improvement in the reflux domain in Stage 1 in ITT-suitable patients with baseline symptoms (p=0.047). Statistically significant changes over 24 months were found in the indigestion domain for ITT-suitable patients and ITT-suitable patients with baseline symptoms (p<0.05 based on the 95% CI not including 0). There was a trend toward improvement in the constipation domain.

TABLE 4 Changes in Gastrointestinal Symptoms Rating Scale¹ (ITT-Suitable) GSRS Domain Treatment Diarrhea Reflux Indigestion Constipation Abdominal Pain Group Migalastat Placebo Migalastat Placebo Migalastat Placebo Migalastat Placebo Migalastat Placebo Mean Baseline Values (n) All patients 2.3 (28) 2.1 (22) 1.4 (28) 1.4 (22) 2.5 (28) 2.4 (22) 1.9 (28) 2.0 (22) 2.1 (28) 2.3 (22) Patients with 3.2 (17) 3.1 (11) 2.1 (10) 2.6 (6)  2.8 (23) 2.7 (19) 2.5 (17) 2.4 (15) 2.4 (22) 2.9 (15) Symptoms at BL Change from Baseline to Month 6 (Stage 1, Double-Blind) All Patients −0.3*² +0.2 −0.1 +0.2 −0.1 −0.1 +0.1 +0.2 0.0 0.0 Patients with −0.6 +0.2 −0.6*³ +0.6 −0.2 −0.2 +0.2 +0.1 −0.1 −0.1 Symptoms at BL Change from Baseline (Migalastat) or Month 6 (Placebo) to Month 24 (OLE Migalastat Treatment) All Patients −0.5 (−0.9, −0.1)*⁴ −0.2 (−0.5, 0.2) −0.4 (−0.7, −0.04)*⁴ −0.4 (−0.7, +0.0)*⁵ −0.2 (−0.5, +0.1) Patients with −1.0 (−1.5, −0.4)*⁴ −0.6 (−1.5, 0.2) −0.5 (−0.8, −0.06)*⁴ −0.5 (−1.1, +0.0)*⁵ −0.2 (−0.6, 0.1)  Symptoms at BL *Indicates significant or borderline significant changes from baseline. ¹Least squares means for change from baseline (BL)| ²p = 0.03 and ³p = 0.047 using ANCOVA| ⁴Statistically significant or ⁵Trend based on 95% CIs with the upper bound of 0.

Migalastat and Podocyte GL-3.

Kidney biopsy samples from ERT-naïve male patients with Fabry disease with GLA mutations amenable to migalastat (N=8), taken at baseline and again after 6 months of migalastat treatment, were studied by masked unbiased electron microscopy stereology. The mean±SD total volume of GL-3 inclusions per podocyte V(Inc/PC) of all patients decreased from 2568±1408 μm³ at baseline to 1282±792 μm³ after 6 months of migalastat (p=0.0182), as shown in FIG. 4. Thus, the reduction in V(Inc/PC) was approximately 50%. There was a correlated reduction in mean podocyte volume from 6680±2835 μm³ at baseline to 3525±2084 μm³ (p=0.004) after 6 months of migalastat (r=0.98, p=0.00003), as shown in FIG. 5. Thus, the reduction in mean podocyte volume was approximately 47%. These findings indicate that the podocyte cytoplasmic shrinkage was proportional to GL-3 loss; thus, the volume fraction of podocyte cytoplasm attributable to GL-3 did not change significantly. The magnitude of podocyte GL-3 volume reduction following migalastat correlated with improvement of foot process width (r=0.82, p=0.02), as shown in FIG. 6. Mean plasma lyso-Gb3 also decreased from 118±48 nM at baseline to 75±42 nM after 6 months of migalastat (p=0.0004), as shown in FIG. 7. This decrease correlated with the percent reduction in podocyte GL-3 volume (r=0.79, p=0.02). There was a trend between decrease in podocyte GL-3 volume and proteinuria (r=0.69, p=0.06) following treatment with migalastat for 6 months as shown in FIG. 8, but no association was found with glomerular filtration rate. In this study, migalastat treatment was associated with a loss of GL-3 inclusions in podocytes in patients with Fabry disease. The sensitive quantitative method used can assess treatment efficacy for this important cell type over a relatively short period of time. This methodology is also more sensitive than other methodologies, including the methodologies used previously in Phase 2 studies and the first methodology described earlier in this example relating to qualitative assessment of podocyte GL-3.

Safety and Adverse Events.

During Stage 1, the treatment-emergent adverse events were similar between groups. Adverse events with a higher frequency in patients receiving migalastat compared to placebo were headache (12/34 patients—35% versus 7/33 patients—21%) and nasopharyngitis (6/34 patients—18% versus 2/34—6%). The most frequently reported adverse events for Stage 2 were headache (9/63 patients—14%) and procedural pain (7/63 patients—11%—related to kidney biopsies) and, for the open-label-extension, proteinuria (9/57 patients—16%), headache (6/57 patients—11%), and bronchitis (6/57 patients—11%). Most adverse events were mild or moderate in severity. No adverse events led to migalastat discontinuation.

Six patients experienced serious adverse events during Stage 1 (2: migalastat; 4: placebo), 5 during Stage 2, and 11 during the open-label-extension. Two serious adverse events were assessed as possibly related to migalastat by the investigator—fatigue and paresthesia. Both occurred in the same patient between months 12-24 and resolved. No individual serious adverse event was reported by >1 patient. Two patients discontinued migalastat due to serious adverse events; both were deemed unrelated to migalastat. No deaths were reported.

Treatment-emergent proteinuria was reported in 9 patients (16%) between months 12-24, and in one case, was judged as migalastat-related. In 5 patients, the 24-month values were in the same range as baseline. Three patients with suitable mutations had overt baseline proteinuria (>1 g/24-hr), which increased over 24 months. In 23/28 patients with baseline proteinuria <300 mg/24-h, 24-hour urine protein remained stable during migalastat treatment.

There was no progression to end-stage renal disease, no cardiac death and no stroke as defined in Banikazemi et al. There was a single case of transient ischemic attack-judged unrelated to migalastat.

Analyses of vital sign, physical findings, laboratory, and ECG parameters did not reveal any clinically relevant effect of migalastat.

Example 2: Dosing Regimens for the Treatment of ERT-Experienced Fabry Patients Using Migalastat Hydrochloride

This example describes a Phase 3 study of migalastat therapy in ERT-experienced Fabry patients.

Patient Enrollment.

Eligible patients were 16-74 years old and had genetically-confirmed Fabry disease; had received ERT for ≥12 months; had a GLA mutation that resulted in a mutant protein that would respond to migalastat, based on the human embryonic kidney-293 (HEK) assay used at the time of enrollment; had an eGFR ≥30 ml/minute/1.73 m²; and had an ERT dose level and regimen that had been stable for at least 3 months.

Study Design.

Following eligibility-baseline assessments, 57 patients were randomized to 18 months of migalastat therapy or ERT, followed by followed by 12 months of migalastat therapy. The migalastat dosing regimen was 150 mg of migalastat hydrochloride every other day. The primary objective was to compare the effect of migalastat to ERT on renal function assessed by mGFR_(iohexol) after 18 months of treatment. The secondary objectives were to compare the effect of migalastat to ERT on: renal function (assessed by eGFR and 24-hour urine protein); composite clinical outcome (assessed by time to occurrence of renal, cardiac, cerebrovascular events or death); cardiac function (assessed by echocardiography) and patient reported outcomes (pain and quality of life).

Results

Migalastat and Echocardiographic Parameters.

This study of ERT-experienced patients found that migalastat therapy reduced LVMi. At month 18, mean changes from baseline were −6.6 g/m² (95% CI −11.0, −2.1; n=31) with migalastat and −2.0 g/m² (95% CI −11.0, 7.0; n=13) with ERT. In patients with LVH at baseline, the change in LVMi from baseline to month 18 was −8.4 g/m² (95% CI: −15.7, 2.6; n=13) for migalastat and 4.5 g/m² (95% CI: −10.7, 18.4; n=5) for ERT.

Patients treated with migalastat continued to show reductions in LVMi at month 30 (−3.8 g/m² [95% CI −8.9, 1.3]; n=30). Greater reductions were seen in patients with baseline LVH (n=13), with a change from baseline of −9.0 g/m² after 30 months of migalastat therapy. Among the Fabry patients with baseline LVH, 85% (11/13) had reductions and 31% (4/13) had normalizations of LVMi after 30 months of migalastat therapy.

Example 3: Comparison of Migalastat Dosing Regimens for the Treatment Fabry Disease

This example describes a series of Phase 2 studies of migalastat therapy in Fabry patients.

A range of doses and regimens were explored in five Phase 2 studies in 27 subjects (18 males and 9 females):

-   -   Twice per day (BID) dosing of 25, 100, and 250 mg of migalastat         hydrochloride;     -   Once per day (QD) dosing of 50 mg of migalastat hydrochloride;     -   Every other day (QOD) dosing of 50, 150, and 250 mg of         migalastat hydrochloride; and     -   3 days on 4 days off dosing of 250 and 500 mg of migalastat         hydrochloride.

In all, 9 different combinations of dosing amounts and dosing schedules were investigated in these Phase 2 studies. Fabry disease is a rare genetic disease, and due to the limited patient population and study sample size for this orphan disease, some of these doses and regimens explored were compared within or across subjects, while others were compared across studies. These five Phase 2 studies were designed to assess the safety, pharmacokinetics and pharmacodynamics of migalastat hydrochloride, with a focus on measures of white blood cell (WBC) α-Gal A activity and urine GL-3 reduction to assess the efficacy of different doses and regimens. WBC α-Gal A activity provides a repeatable, minimally invasive measure of the magnitude of enzyme activity increase associated with different doses of migalastat hydrochloride, and was correlated with less frequently assessed, invasive measures of enzyme activity in skin and kidney. Urine GL-3 provides a repeatable, minimally invasive measure of GL-3 breakdown within lysosomes, the penultimate step in the mechanism of action pathway.

In these Phase 2 studies, 150 mg every other day (QOD) resulted in the largest reductions in urine GL-3 in subjects with migalastat-responsive mutations and was generally well tolerated. The urine GL-3 levels for the QOD regimens are shown in FIGS. 9 and 10, and the 8 patients that were on the 150 mg QOD regimen and that had amenable mutations based on the HEK-293 cell-based assay are indicated by the arrows.

In one of the Phase 2 studies, patients were administered migalastat hydrochloride according to the following dosing schedule: 25 mg BID for the first two weeks; 100 mg BID for weeks 2-4; 200 mg BID for weeks 4-6; 25 mg BID for weeks 6-12; and an optional extension of the study at 50 mg per day dosing until up to week 96. The urine GL-3 results from this study are shown in Table 5 below.

TABLE 5 Urine GL-3 Total^(a) Urine GL-3, pmol/nmol PC Baseline Week 2 Week 4 Week 6 Week 12 Week 24 Week 48 Week 96 ATI00I dose: 25 mg 100 mg 250 mg 25 mg 50 mg 50 mg 50 mg 0 BID BID BID BID QD QD QD 01-01  66.5 

72.7 155.5  371.0 

54.2 55.5 50.8 52.1 01-02  49.4 

38.1 71.7  107.1 

47.8 61.0 63.5 39.4 01-03  64.1 

61.4 93.7  110.2 

106.3 68.2 49.3 68.3 01-04  159.0 

198.8 272.4  556.4 

140.2 139.1 120.6 131.6 01-05  75.5 69.4 01-06  851.9 

1641.3 2062.3 1816.0 

1914.0 1669.2 1750.6 2266.5 02-04 2212.3 3508.8 2625.8 1845.5 469.9 1435.0 02-05 4091.0 2653.0 2575.9 1784.9 1368.9 1290.8 03-05  457.7 

800.5 619.7  984.6 

1859.7 2647.6 2160.8 PC = phosphatidylcholine. ^(a)Total represents the sum of the five isoforms of GL-3 measured.

Twice-daily dosing at 25, 100 and 250 mg resulted in increases in α-Gal A activity. An increase in α-Gal A activity would be expected to have a positive treatment effect (such as a reduction in build-up of enzyme substrate GL-3). Unexpectedly, Table 5 above shows that there were urine GL-3 increases in a majority of subjects on the BID regimen, which indicates a possible negative effect. This increase in urine GL-3 was possibly due to the high frequency dose interval. When these subjects on a BID regimen were switched to 50 mg per day, some patients demonstrated reductions in urine GL-3, but results were not consistent across all patients. Although pharmacokinetic modelling indicated the 50 mg per day dose should provide exposure troughs below IC₅₀ (i.e. below inhibition), urine GL-3 was not as consistently reduced as it was with 150 mg QOD As can be seen by comparing FIGS. 9 and 10 with Table 5, 150 mg QOD provided much larger and more consistent declines in urine GL-3 than dosing every day or twice a day.

A further study was intended to explore the possibility that less-frequent administration of higher doses of migalastat may provide greater substrate reduction than a 150 mg every other day regimen. Subjects were switched from 150 mg migalastat hydrochloride QOD to 250 mg administered once daily for 3 consecutive days (“on drug” period), followed by 4 days without dosing (“off drug” period) for 8 weeks and then 500 mg (3 days on, 4 days off) for at least 8 weeks. A few subjects showed an increase in WBC α-Gal A levels at the higher doses; however, some subjects also showed signs of increases in urine GL-3. As illustrated in Table 6 below, mean and median urine GL-3 levels increased after subjects were switched from 150 mg QOD to 250 and 500 mg 3 on 4 off. Mean and median urine GL-3 then went back down when subjects were switched back to 150 mg QOD. Additionally, a few subjects did not tolerate the higher doses.

TABLE 6 Urine GL-3 Study Fab-205 Urine GL-3 Results (preliminary) DEP Visit 1 n 12 All Amenable Mean (SD) 342.069 (531.1137) subjects on 150 mg Median 77.71 QOD Min, Max 30.68, 1538.33 DEP Visit 4 n 16 All Amenable Mean (SD) 520.027 (690.3037) subjects after Median 168.85 switching to 250 mg Min, Max 28.96, 2503.34 3 on 4 off for 8 wks Visit 6 n 15 All Amenable Mean (SD)  937.733 (1502.4504) subjects after Median 321.70 switching to 500 mg Min, Max 30.10, 5561.42 3 on 4 off for 8 wks Visit 10 n 13 All Amenable Mean (SD)  659.829 (1054.5852) subjects after Median 278.06 being on 500 mg Min, Max 41.68, 3976.42 3 on 4 off for >1 year Visit 14 n 11 All Amenable Mean (SD) 354.549 (483.1105) subjects after Median 111.62 switching back Min, Max 32.86, 1418.94 to 150 mg QOD for 3-6 months Visit 18 n 11 All Amenable Mean (SD) 609.767 (782.6499) subjects after Median 177.31 being back on Min, Max 52.76, 2445.41 150 mg QOD for >1 year

Based on the results of these studies, dosing every other day provides unexpected benefits that are not present with either daily or twice daily dosing. In particular, dosing every other day in resulted in the most consistent reductions in urine GL-3 in subjects with migalastat-responsive mutations. Indeed, many of the other dosing regimens actually lead to increases in urine GL-3. Dosing every other day also led to a more consistent decrease in urine GL-3 than 3 days on 4 days off dosing, and some of these patients on the 3 days on 4 days off dosing also showed an increase in urine GL-3. Returning to 150 mg QOD after the 3 days on 4 days off dosing lowered the mean and median urine GL-3 levels.

The embodiments described herein are intended to be illustrative of the present compositions and methods and are not intended to limit the scope of the present invention. Various modifications and changes consistent with the description as a whole and which are readily apparent to the person of skill in the art are intended to be included. The appended claims should not be limited by the specific embodiments set forth in the examples, but should be given the broadest interpretation consistent with the description as a whole.

Patents, patent applications, publications, product descriptions, GenBank Accession Numbers, and protocols are cited throughout this application, the disclosures of which are incorporated herein by reference in their entireties for all purposes. 

1. A method of reducing left ventricular mass index (LVMi) in an enzyme replacement therapy (ERT)-experienced patient having Fabry disease, the method comprising administering to the patient a formulation comprising an effective amount of migalastat or salt thereof every other day, wherein the effective amount is about 123 mg free base equivalent (FBE).
 2. The method of claim 1, wherein the patient has left ventricular hypertrophy (LVH) prior to initiating administration of the migalastat or salt thereof.
 3. The method of claim 1, wherein the migalastat or salt thereof enhances α-galactosidase A activity.
 4. The method of claim 1, wherein the patient is administered about 123 mg of migalastat free base every other day.
 5. The method of claim 1, wherein the patient is administered about 150 mg of migalastat hydrochloride every other day.
 6. The method of claim 1, wherein the formulation comprises an oral dosage form.
 7. The method of claim 6, wherein the oral dosage form comprises a tablet, a capsule or a solution.
 8. The method of claim 1, wherein the migalastat or salt thereof is administered for at least 18 months.
 9. The method of claim 1, wherein the migalastat or salt thereof is administered for at least 30 months.
 10. The method of claim 1, wherein the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-experienced patients of at least about 5 g/m² after 18 months of administration of migalastat or a salt thereof.
 11. (canceled)
 12. The method of claim 1, wherein the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-experienced patients of at least about 2 g/m² after 30 months of administration of migalastat or a salt thereof.
 13. (canceled)
 14. The method of claim 1, wherein the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-experienced patients with LVH of at least about 5 g/m² after 30 months of administration of migalastat or a salt thereof. 15-39. (canceled)
 40. A method of normalizing left ventricular mass index (LVMi) in an enzyme replacement therapy (ERT)-experienced patient having Fabry disease, the method comprising administering to the patient a formulation comprising an effective amount of migalastat or salt thereof every other day, wherein the effective amount is about 123 mg free base equivalent (FBE).
 41. The method of claim 40, wherein the patient has left ventricular hypertrophy (LVH) prior to initiating administration of the migalastat or salt thereof.
 42. The method of claim 4, wherein the migalastat or salt thereof enhances α-galactosidase A activity.
 43. The method of claim 40, wherein the patient is administered about 123 mg of migalastat free base every other day.
 44. The method of claim 40, wherein the patient is administered about 150 mg of migalastat hydrochloride every other day.
 45. The method of claim 40, wherein the formulation comprises an oral dosage form.
 46. The method of claim 45, wherein the oral dosage form comprises a tablet, a capsule or a solution.
 47. The method of claim 40, wherein the migalastat or salt thereof is administered for at least 18 months.
 48. The method of claim 40, wherein the migalastat or salt thereof is administered for at least 30 months.
 49. The method of claim 40, wherein the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-experienced patients of at least about 5 g/m² after 18 months of administration of migalastat or a salt thereof.
 50. (canceled)
 51. The method of claim 40, wherein the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-experienced patients of at least about 2 g/m² after 30 months of administration of migalastat or a salt thereof.
 52. (canceled)
 53. The method of claim 40, wherein the administration of migalastat or a salt thereof provides an average decrease of LVMi in a group of ERT-experienced patients with LVH of at least about 5 g/m² after 30 months of administration of migalastat or a salt thereof. 54-200. (canceled) 